Healthcare Provider Details

I. General information

NPI: 1750963146
Provider Name (Legal Business Name): MIO OKUYAMA L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2021
Last Update Date: 04/25/2021
Certification Date: 04/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E 55TH STREET 1ST FLOOR
NEW YORK NY
10022
US

IV. Provider business mailing address

150 E 55TH STREET 1ST FLOOR
NEW YORK NY
10022
US

V. Phone/Fax

Practice location:
  • Phone: 646-476-2263
  • Fax:
Mailing address:
  • Phone: 646-476-2263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number003914
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: