Provider Demographics
NPI:1225461023
Name:SACRED SPACE ACUPUNCTURE INC
Entity Type:Organization
Organization Name:SACRED SPACE ACUPUNCTURE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING REPRESENTATIVE
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HILDERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-683-3855
Mailing Address - Street 1:97 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-4434
Mailing Address - Country:US
Mailing Address - Phone:347-886-9695
Mailing Address - Fax:
Practice Address - Street 1:97 S BROADWAY
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-4434
Practice Address - Country:US
Practice Address - Phone:347-886-9695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0027681171100000X
NY0180411225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty