Healthcare Provider Details

I. General information

NPI: 1588978811
Provider Name (Legal Business Name): AUTUM LEIGH ROTACH L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 JOHN ST
BARNEVELD NY
13304-2911
US

IV. Provider business mailing address

10700 JOHN ST
BARNEVELD NY
13304-2911
US

V. Phone/Fax

Practice location:
  • Phone: 917-455-2032
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number004409
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: