Provider Demographics
NPI:1235796822
Name:CLASSICAL ACUPUNCTURE CLINIC
Entity Type:Organization
Organization Name:CLASSICAL ACUPUNCTURE CLINIC
Other - Org Name:CLASSICAL ACUPUNCTURE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOZAK
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:904-806-3441
Mailing Address - Street 1:260 PASEO REYES DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8462
Mailing Address - Country:US
Mailing Address - Phone:904-806-3441
Mailing Address - Fax:904-592-5370
Practice Address - Street 1:260 PASEO REYES DR
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8462
Practice Address - Country:US
Practice Address - Phone:904-806-3441
Practice Address - Fax:904-592-5370
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRACY L KOZAK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-20
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty