Healthcare Provider Details

I. General information

NPI: 1790821239
Provider Name (Legal Business Name): JONATHAN S THALER NYS L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 N RIDGE RD POB 611
SHRUB OAK NY
10588-1033
US

IV. Provider business mailing address

1220 NORTH RIDGE RD. ,POB 611 POB 611
SHRUB OAK NY
10588-0611
US

V. Phone/Fax

Practice location:
  • Phone: 914-528-8770
  • Fax:
Mailing address:
  • Phone: 914-528-8770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number000697
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: