Healthcare Provider Details

I. General information

NPI: 1134272198
Provider Name (Legal Business Name): PETER M ANGELO L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 COMMERCE ST
THORNWOOD NY
10594-1353
US

IV. Provider business mailing address

104 ORCHARD TER
PIERMONT NY
10968-1063
US

V. Phone/Fax

Practice location:
  • Phone: 914-769-0683
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number000639
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberMZ000172
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: