MEDICARE: ROSS ANTI MSTOM, LAC

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	171400000X	Health & Wellness Coach
2	171100000X	Acupuncturist	007222	NY

General Provider Information

NPI Number	:	1750144663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSS ANTI MSTOM, LAC

Provider Business Mailing Address
First Line	:	239 BANKER ST APT 4P
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11222-2687
Country	:	US
Telephone Number	:	781-413-7834
Fax Number	:

Provider Business Practice Location Address
First Line	:	256 WEST ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10013-2014
Country	:	US
Telephone Number	:	212-431-5752
Fax Number	:

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

Provider Enumeration Date	:	02/02/2024
Last Update Date	:	02/02/2024

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