Healthcare Provider Details

I. General information

NPI: 1740639806
Provider Name (Legal Business Name): LODES ACUPUNCTURE AND PHYSICAL THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6937 MYRTLE AVE
GLENDALE NY
11385-7265
US

IV. Provider business mailing address

6937 MYRTLE AVE
GLENDALE NY
11385-7265
US

V. Phone/Fax

Practice location:
  • Phone: 347-665-8446
  • Fax: 718-381-0700
Mailing address:
  • Phone: 347-665-8446
  • Fax: 718-381-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number0045351
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number0271821
License Number StateNY

VIII. Authorized Official

Name: JESSIE JIMENEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 347-665-8446