Provider Demographics
NPI:1841996436
Name:MOON TIDES ACUPUNCTURE, INC.
Entity type:Organization
Organization Name:MOON TIDES ACUPUNCTURE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:YORK
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, MSTOM
Authorized Official - Phone:910-274-6711
Mailing Address - Street 1:401 S 5TH AVE UNIT D
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-5187
Mailing Address - Country:US
Mailing Address - Phone:910-274-6711
Mailing Address - Fax:
Practice Address - Street 1:516 PRINCESS ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4131
Practice Address - Country:US
Practice Address - Phone:910-367-5747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1629527874OtherINDIVIDUAL NPI