Healthcare Provider Details

I. General information

NPI: 1265624373
Provider Name (Legal Business Name): SONIA MARTINEZ LONDON L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 BELLE TERRE ROAD, BLDG. F
PORT JEFFERSON NY
11777-0000
US

IV. Provider business mailing address

1 VILLAGE HILL DR
DIX HILLS NY
11746-5512
US

V. Phone/Fax

Practice location:
  • Phone: 631-291-7006
  • Fax:
Mailing address:
  • Phone: 631-291-7006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number2667
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: