=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144753930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHOLD ACUPUNCTURE & MASSAGE THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2017
-----------------------------------------------------
Last Update Date | 04/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53345 MAIN RD
-----------------------------------------------------
City | SOUTHOLD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11971-4643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-765-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 523
-----------------------------------------------------
City | SOUTHOLD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11971-0523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARRIE IMPERATO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-765-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number | 022202
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 005542
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------