Healthcare Provider Details

I. General information

NPI: 1205099793
Provider Name (Legal Business Name): MATTHEW FELLNER LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CHRISTOPHER COLUMBUS DR STE 3A
JERSEY CITY NJ
07302-3432
US

IV. Provider business mailing address

107 HAWTHORNE AVE APT E
PARK RIDGE NJ
07656-3205
US

V. Phone/Fax

Practice location:
  • Phone: 201-724-3998
  • Fax:
Mailing address:
  • Phone: 201-694-1353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00051400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: