Provider Demographics
NPI:1699593079
Name:SACK, ALEXANDRA (LAC)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:SACK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FRANKLIN AVE UNIT 507
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3279
Mailing Address - Country:US
Mailing Address - Phone:941-928-1500
Mailing Address - Fax:
Practice Address - Street 1:25-15 FAIR LAWN AVE STE 4
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3434
Practice Address - Country:US
Practice Address - Phone:201-916-0509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00173400171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist