Healthcare Provider Details

I. General information

NPI: 1144753930
Provider Name (Legal Business Name): SOUTHOLD ACUPUNCTURE & MASSAGE THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53345 MAIN RD
SOUTHOLD NY
11971-4643
US

IV. Provider business mailing address

PO BOX 523
SOUTHOLD NY
11971-0523
US

V. Phone/Fax

Practice location:
  • Phone: 631-765-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number005542
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number022202
License Number StateNY

VIII. Authorized Official

Name: CARRIE IMPERATO
Title or Position: OWNER
Credential:
Phone: 631-765-2100