=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467757484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OB ACUPUNCTURE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2011
-----------------------------------------------------
Last Update Date | 01/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 FULTON AVE SUITE 10
-----------------------------------------------------
City | HEMPSTEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11550-3646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-292-2993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2940 W 5TH ST 18B
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11224-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | OLEG BAZYLKO
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 516-292-2993
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------