Healthcare Provider Details

I. General information

NPI: 1609605526
Provider Name (Legal Business Name): CLEAR LAKE MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 NEW DORP LN
STATEN ISLAND NY
10306-2324
US

IV. Provider business mailing address

93 NEW DORP LN
STATEN ISLAND NY
10306-2324
US

V. Phone/Fax

Practice location:
  • Phone: 718-435-1025
  • Fax: 718-435-2670
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHE LIU
Title or Position: OWNER
Credential: MD
Phone: 646-409-2508