Provider Demographics
NPI: | 1710375738 |
---|---|
Name: | ANCIENT & MODERN ACUPUNCTURE P.C. |
Entity Type: | Organization |
Organization Name: | ANCIENT & MODERN ACUPUNCTURE P.C. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | ACUPUNCTURIST |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | YEVGENIY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | VOLOSHCHUK |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LAC |
Authorized Official - Phone: | 917-658-0152 |
Mailing Address - Street 1: | 2800 COYLE ST |
Mailing Address - Street 2: | APT.321 |
Mailing Address - City: | BROOKLYN |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11235-1747 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 917-658-0152 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1534 BROADWAY |
Practice Address - Street 2: | |
Practice Address - City: | BROOKLYN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11221-4249 |
Practice Address - Country: | US |
Practice Address - Phone: | 718-576-6266 |
Practice Address - Fax: | 718-576-6269 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-12-29 |
Last Update Date: | 2014-12-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 002065 | 302R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 302R00000X | Managed Care Organizations | Health Maintenance Organization |