=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205379849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNDALA ON THE FARM INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2016
-----------------------------------------------------
Last Update Date | 12/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 S GREENBUSH RD BUILDING 4
-----------------------------------------------------
City | ORANGEBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10962-1322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-261-1495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 S GREENBUSH RD BUILDING 4
-----------------------------------------------------
City | ORANGEBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10962-1322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-261-1495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. JODIE TASSELLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 914-261-1495
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 004419
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------