Provider Demographics
NPI:1740638139
Name:EAST SIDE ACUPUNCTURE
Entity type:Organization
Organization Name:EAST SIDE ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:315-569-6579
Mailing Address - Street 1:7211 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1262
Mailing Address - Country:US
Mailing Address - Phone:315-569-6579
Mailing Address - Fax:315-637-3999
Practice Address - Street 1:7211 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1262
Practice Address - Country:US
Practice Address - Phone:315-569-6579
Practice Address - Fax:315-637-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4092171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty