Healthcare Provider Details

I. General information

NPI: 1710613609
Provider Name (Legal Business Name): RADICARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 BOUCK AVE APT 2B
BRONX NY
10469-5752
US

IV. Provider business mailing address

2317 BOUCK AVE APT 2B
BRONX NY
10469-5752
US

V. Phone/Fax

Practice location:
  • Phone: 201-446-1717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name: MRS. ZARIEL GRULLON
Title or Position: REGISTERED DIETITIAN
Credential: RD
Phone: 201-446-1717