Provider Demographics
NPI:1518550128
Name:REN, SOPHIE
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:REN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 E MIDDLE COUNTRY RD STE 3
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2822
Mailing Address - Country:US
Mailing Address - Phone:631-780-5511
Mailing Address - Fax:
Practice Address - Street 1:323 E MIDDLE COUNTRY RD STE 3
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2822
Practice Address - Country:US
Practice Address - Phone:631-780-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006855171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006855Other171100000X
NY1234622Other171100000X