Healthcare Provider Details

I. General information

NPI: 1083518831
Provider Name (Legal Business Name): LAURA LUCY GRILLO LAC, MACOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MAIN ST STE 1
ESPERANCE NY
12066-3219
US

IV. Provider business mailing address

132 FRISBIEVILLE RD
SCHOHARIE NY
12157-2709
US

V. Phone/Fax

Practice location:
  • Phone: 518-932-7807
  • Fax:
Mailing address:
  • Phone: 518-932-7807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number007978-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: