Healthcare Provider Details

I. General information

NPI: 1477019958
Provider Name (Legal Business Name): ESOTERRA ACUPUNCTURE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 W 45 ST STE 501
NEW YORK NY
10036
US

IV. Provider business mailing address

19 W 45 ST STE 501
NEW YORK NY
10036
US

V. Phone/Fax

Practice location:
  • Phone: 833-768-3772
  • Fax:
Mailing address:
  • Phone: 833-768-3772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ENENSAAUAS RASTRYGINA
Title or Position: CEO
Credential: DAC.
Phone: 833-768-3772