MEDICARE: SUP ACUPUNCTURE PLLC

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	005527	NY

General Provider Information

NPI Number	:	1629599246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUP ACUPUNCTURE PLLC

Provider Business Mailing Address
First Line	:	664 MAY ST
Second Line	:
City	:	SOUTH HEMPSTEAD
State	:	NY
Zip	:	11550-7925
Country	:	US
Telephone Number	:	516-474-9668
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 ROUTE 112
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-8051
Country	:	US
Telephone Number	:	516-474-9668
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LIPING JIN
Credential	:	LAC
Telephone Number	:	516-474-9668

Provider Enumeration Date	:	07/05/2017
Last Update Date	:	07/05/2017

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