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General NPI Number Information
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NPI Number | 1386988921
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Entity Type | Organization
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Legal Business Name | BLVD SKIN CLINIC
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Dates
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Enumeration Date | 11/20/2012
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Last Update Date | 11/20/2012
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Provider Practice Location Address
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Address Line | 8635 QUEENS BLVD 1-A
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City | ELMHURST
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State | NY
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Zip | 11373-4434
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Country | US
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Telephone | 917-943-3682
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Fax |
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Provider Business Mailing Address
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Address Line | 8635 QUEENS BLVD 1-A
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City | ELMHURST
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State | NY
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Zip | 11373-4434
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Country | US
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Telephone | 917-943-3682
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Fax |
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Authorized Official
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Title or Position | ACUPUNCTURIST
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Name | TRACEY DE COSTA BYER
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Credential | L.AC.
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Telephone | 917-943-3682
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 004720
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License Number State | NY
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