=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518487859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCED WELLNESS ACUPUNCTURE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2017
-----------------------------------------------------
Last Update Date | 08/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 N LONG BEACH RD
-----------------------------------------------------
City | ROCKVILLE CENTRE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11570-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-316-7076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1085 CENTRAL AVE
-----------------------------------------------------
City | SOUTH HEMPSTEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11550-7919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-316-7076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TERESA SUSKO
-----------------------------------------------------
Credential | L.AC
-----------------------------------------------------
Telephone | 516-316-7076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 005232-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------