Healthcare Provider Details

I. General information

NPI: 1588069488
Provider Name (Legal Business Name): STEPHANIE RAINE YEE LOONG LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6141 62ND AVE
MIDDLE VILLAGE NY
11379-1008
US

IV. Provider business mailing address

6043 68TH AVE
RIDGEWOOD NY
11385-4543
US

V. Phone/Fax

Practice location:
  • Phone: 720-233-7741
  • Fax:
Mailing address:
  • Phone: 720-233-7741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number005458-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: