Healthcare Provider Details

I. General information

NPI: 1790432854
Provider Name (Legal Business Name): JOSEPH VACCARELLA RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 N FEDERAL HWY # 419
FORT LAUDERDALE FL
33308-1998
US

IV. Provider business mailing address

1120 SE 22ND AVE
POMPANO BEACH FL
33062-7046
US

V. Phone/Fax

Practice location:
  • Phone: 954-774-7800
  • Fax:
Mailing address:
  • Phone: 954-512-0726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND7045
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: