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General NPI Number Information
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NPI Number | 1629599246
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Entity Type | Organization
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Legal Business Name | SUP ACUPUNCTURE PLLC
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Dates
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Enumeration Date | 07/05/2017
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Last Update Date | 07/05/2017
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Provider Practice Location Address
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Address Line | 1075 ROUTE 112
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-8051
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Country | US
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Telephone | 516-474-9668
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Fax |
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Provider Business Mailing Address
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Address Line | 664 MAY ST
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City | SOUTH HEMPSTEAD
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State | NY
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Zip | 11550-7925
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Country | US
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Telephone | 516-474-9668
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LIPING JIN
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Credential | LAC
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Telephone | 516-474-9668
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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 | 005527
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License Number State | NY
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