Provider Demographics
NPI:1649587353
Name:SALAZAR, WILSON GEOVANNY (L AC)
Entity Type:Individual
Prefix:MR
First Name:WILSON
Middle Name:GEOVANNY
Last Name:SALAZAR
Suffix:
Gender:M
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 1:114 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-4934
Mailing Address - Country:US
Mailing Address - Phone:646-338-3364
Mailing Address - Fax:
Practice Address - Street 1:280 ROUTE 211 E STE 2
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-3100
Practice Address - Country:US
Practice Address - Phone:845-775-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002756171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist