Provider Demographics
NPI:1093167991
Name:GARDEN STATE ACUPUNCTURE AND WELLNESS
Entity Type:Organization
Organization Name:GARDEN STATE ACUPUNCTURE AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM, LAC
Authorized Official - Phone:302-249-0143
Mailing Address - Street 1:1116 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASBURY PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-4905
Mailing Address - Country:US
Mailing Address - Phone:302-249-0143
Mailing Address - Fax:732-775-3515
Practice Address - Street 1:415 ROUTE 34
Practice Address - Street 2:SUITE 210
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-2522
Practice Address - Country:US
Practice Address - Phone:302-249-0143
Practice Address - Fax:732-775-3515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00104200171100000X
NJ18KT00938000225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty