Healthcare Provider Details

I. General information

NPI: 1588222509
Provider Name (Legal Business Name): STONY BROOK ACUPUNCTURE AND MASSAGE THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 HALLOCK RD STE 6A
STONY BROOK NY
11790-3077
US

IV. Provider business mailing address

215 HALLOCK RD STE 6A
STONY BROOK NY
11790-3077
US

V. Phone/Fax

Practice location:
  • Phone: 917-563-1824
  • Fax: 929-900-1843
Mailing address:
  • Phone: 917-563-1824
  • Fax: 929-900-1843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: JONGKOO AHN
Title or Position: PROVIDER
Credential: LAC, MT
Phone: 917-563-1824