MEDICARE: STEPHANIE CLARK ELLIS L.AC.

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	001927	NY

General Provider Information

NPI Number	:	1609914217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE CLARK ELLIS L.AC.

Provider Business Mailing Address
First Line	:	7 KELLARS LN
Second Line	:
City	:	TILLSON
State	:	NY
Zip	:	12486-1224
Country	:	US
Telephone Number	:	845-546-5358
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 CREEK LOCKS RD
Second Line	:
City	:	ROSENDALE
State	:	NY
Zip	:	12472-9678
Country	:	US
Telephone Number	:	845-546-5358
Fax Number	:

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

Provider Enumeration Date	:	02/03/2007
Last Update Date	:	07/08/2007

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