MEDICARE: JACK MA ACUPUNCTURIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	005627	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5627	OTHER	NY	ACCUPUNCTURE
2	25MZ001172000	OTHER	NJ	ACUPUNCTURE

General Provider Information

NPI Number	:	1447629928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK MA ACUPUNCTURIST

Provider Business Mailing Address
First Line	:	20644 45TH RD
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11361-3121
Country	:	US
Telephone Number	:	646-479-7689
Fax Number	:

Provider Business Practice Location Address
First Line	:	53 WOODBURY RD
Second Line	:
City	:	HICKSVILLE
State	:	NY
Zip	:	11801-3041
Country	:	US
Telephone Number	:	646-479-7689
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2015
Last Update Date	:	04/17/2019

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