MEDICARE: EMERALD ACUPUNCTURE WELLNESS PC

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

General Provider Information

NPI Number	:	1932761103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD ACUPUNCTURE WELLNESS PC

Provider Business Mailing Address
First Line	:	315 WALT WHITMAN RD STE 311
Second Line	:
City	:	HUNTINGTON STATION
State	:	NY
Zip	:	11746-4112
Country	:	US
Telephone Number	:	718-841-7392
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 WALT WHITMAN RD STE 311
Second Line	:
City	:	HUNTINGTON STATION
State	:	NY
Zip	:	11746-4112
Country	:	US
Telephone Number	:	718-841-7392
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JIYOON KIM
Credential	:	LAC
Telephone Number	:	718-841-7392

Provider Enumeration Date	:	07/08/2019
Last Update Date	:	07/08/2019

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