Provider Demographics
NPI:1437535879
Name:ELYSIAN FOREST ACUPUNCTURE
Entity Type:Organization
Organization Name:ELYSIAN FOREST ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MS
Authorized Official - First Name:RHEA
Authorized Official - Middle Name:THERESA
Authorized Official - Last Name:BRODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, RT
Authorized Official - Phone:347-927-4324
Mailing Address - Street 1:1207 E 45TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-1429
Mailing Address - Country:US
Mailing Address - Phone:347-927-4324
Mailing Address - Fax:
Practice Address - Street 1:1207 E 45TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-1429
Practice Address - Country:US
Practice Address - Phone:347-927-4324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-08
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25 005552171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty