Provider Demographics
NPI:1144753930
Name:SOUTHOLD ACUPUNCTURE & MASSAGE THERAPY PLLC
Entity Type:Organization
Organization Name:SOUTHOLD ACUPUNCTURE & MASSAGE THERAPY PLLC
Other - Org Name:EASTERM SUN HOLISTIC HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:IMPERATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-765-2100
Mailing Address - Street 1:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-0523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53345 MAIN RD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-4643
Practice Address - Country:US
Practice Address - Phone:631-765-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005542171100000X
NY022202405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty