MEDICARE: ANCIENT & MODERN ACUPUNCTURE P.C.

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	302R00000X	Health Maintenance Organization	002065	NY

General Provider Information

NPI Number	:	1710375738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANCIENT & MODERN ACUPUNCTURE P.C.

Provider Business Mailing Address
First Line	:	2800 COYLE ST
Second Line	:	APT.321
City	:	BROOKLYN
State	:	NY
Zip	:	11235-1747
Country	:	US
Telephone Number	:	917-658-0152
Fax Number	:

Provider Business Practice Location Address
First Line	:	1534 BROADWAY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11221-4249
Country	:	US
Telephone Number	:	718-576-6266
Fax Number	:	718-576-6269

Authorized Official
Title or Position	:	ACUPUNCTURIST
Name	:	MR. YEVGENIY VOLOSHCHUK
Credential	:	LAC
Telephone Number	:	917-658-0152

Provider Enumeration Date	:	12/29/2014
Last Update Date	:	12/29/2014

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