=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760717722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILTON VALERIO MSTOM, L.AC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2009
-----------------------------------------------------
Last Update Date | 01/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 2ND AVE STE 2
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-2746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-842-0420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 W 168TH ST APT 5B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-842-0420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 003979
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------