Healthcare Provider Details

I. General information

NPI: 1508630583
Provider Name (Legal Business Name): RADIANCE ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2023
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 ECHO AVE
MOUNT SINAI NY
11766-2000
US

IV. Provider business mailing address

110 TUDOR LN
MIDDLE ISLAND NY
11953-1362
US

V. Phone/Fax

Practice location:
  • Phone: 631-476-4855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: GAETANO PITTALA
Title or Position: OWNER
Credential:
Phone: 631-745-1009