Healthcare Provider Details

I. General information

NPI: 1225461023
Provider Name (Legal Business Name): SACRED SPACE ACUPUNCTURE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2013
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 S BROADWAY
NYACK NY
10960-4434
US

IV. Provider business mailing address

97 S BROADWAY
NYACK NY
10960-4434
US

V. Phone/Fax

Practice location:
  • Phone: 347-886-9695
  • Fax:
Mailing address:
  • Phone: 347-886-9695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0027681
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0180411
License Number StateNY

VIII. Authorized Official

Name: MS. DEBORAH HILDERLEY
Title or Position: BILLING REPRESENTATIVE
Credential:
Phone: 352-683-3855