Healthcare Provider Details

I. General information

NPI: 1538772470
Provider Name (Legal Business Name): STONYBROOKSETAUKET ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2020
Last Update Date: 08/29/2020
Certification Date: 08/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 ETHAN ALLAN CT
SOUTH SETAUKET NY
11720-4608
US

IV. Provider business mailing address

5 ETHAN ALLAN CT
SOUTH SETAUKET NY
11720-4608
US

V. Phone/Fax

Practice location:
  • Phone: 631-738-9368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: BIN Y
Title or Position: LAC/PRESIDENT
Credential: MD
Phone: 631-738-9368