Provider Demographics
NPI:1245775824
Name:PODNEBESNYKH, ALI (L AC)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:PODNEBESNYKH
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 S ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-2258
Mailing Address - Country:US
Mailing Address - Phone:732-997-4988
Mailing Address - Fax:
Practice Address - Street 1:557 S ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NJ
Practice Address - Zip Code:07747-2258
Practice Address - Country:US
Practice Address - Phone:732-997-4988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00122300171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist