Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 019032 | NY |
NPI | 1366962185 |
---|---|
Provider Name | Mr. Michael Louis Scicchitano SR. |
First Address | Port Jefferson Station, NY 11776-2803 |
Second Address | Port Jefferson Station, NY 11776 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2017 |
Last Update Date | 22/06/2017 |