Provider Demographics
NPI:1659705119
Name:RE', ADAM (LAC)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:RE'
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 HORTON CT
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-1107
Mailing Address - Country:US
Mailing Address - Phone:631-433-4321
Mailing Address - Fax:
Practice Address - Street 1:650 HAWKINS AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2366
Practice Address - Country:US
Practice Address - Phone:631-981-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-02
Last Update Date:2013-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004864-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist