=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861165599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NY STATE ACUPUNCTURE WELLNESS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2021
-----------------------------------------------------
Last Update Date | 07/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 MILTON RD
-----------------------------------------------------
City | RYE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10580-3812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-362-8400
-----------------------------------------------------
Fax | 845-362-8474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 MILTON RD
-----------------------------------------------------
City | RYE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10580-3812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-362-8400
-----------------------------------------------------
Fax | 845-362-8474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HAROLDO JEZLER
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 800-750-8616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------