Healthcare Provider Details

I. General information

NPI: 1477855963
Provider Name (Legal Business Name): SANDRA L OWEN-KELLY L AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2010
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

466 OLD RTE 17
LIVINGSTON MANOR NY
12758-1147
US

IV. Provider business mailing address

PO BOX 1147
LIVINGSTON MANOR NY
12758-1147
US

V. Phone/Fax

Practice location:
  • Phone: 845-439-4471
  • Fax: 845-439-4471
Mailing address:
  • Phone: 845-439-4471
  • Fax: 845-439-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number002488-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: