1124777305 NPI number — FORGET ME NOT ACUPUNCTURE PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124777305 NPI number — FORGET ME NOT ACUPUNCTURE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORGET ME NOT ACUPUNCTURE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124777305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
363 HAUPPAUGE RD, SUITE 97, NY-111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMITHTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-257-5663
Provider Business Mailing Address Fax Number:
631-257-5664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
363 HAUPPAUGE RD, NY-111
Provider Second Line Business Practice Location Address:
SUITE 97
Provider Business Practice Location Address City Name:
SMITHTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11787
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-257-5663
Provider Business Practice Location Address Fax Number:
631-257-5664
Provider Enumeration Date:
03/23/2022

Additional Information

Authorized Official

Authorized Official Last Name:
GOUSSE
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
ACUPUNCTURIST
Authorized Official Telephone Number:
631-257-5663

Provider Taxonomy Codes

  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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