Provider Demographics
NPI:1386997823
Name:MAYNARD CLINIC OF ACUPUNCTURE & ORIENTAL MEDICINE
Entity type:Organization
Organization Name:MAYNARD CLINIC OF ACUPUNCTURE & ORIENTAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:WALDRON
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:917-941-5180
Mailing Address - Street 1:22 SYLVAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 SYLVAN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2087
Practice Address - Country:US
Practice Address - Phone:917-941-5180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004865171100000X
NJ25MZ00094000171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty