Provider Demographics
NPI:1760250831
Name:CITY SOUL ACUPUNCTURE, PLLC
Entity Type:Organization
Organization Name:CITY SOUL ACUPUNCTURE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WILTSE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:646-701-2012
Mailing Address - Street 1:82 NASSAU ST STE 208
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-3703
Mailing Address - Country:US
Mailing Address - Phone:212-804-7267
Mailing Address - Fax:212-518-0578
Practice Address - Street 1:43 E 10TH ST APT 6H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6106
Practice Address - Country:US
Practice Address - Phone:212-804-7267
Practice Address - Fax:212-518-0578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-18
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007338OtherNEW YORK STATE ACUPUNCTURE LICENSE - LISA WILTSE
NY006308-1OtherNEW YORK STATE ACUPUNCTURE LICENSE - EDWIN WILTSE