Healthcare Provider Details

I. General information

NPI: 1215345947
Provider Name (Legal Business Name): DYANNA RETTIG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 07/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 MAIN ST
CORNWALL NY
12518-1554
US

IV. Provider business mailing address

306 MAIN ST
CORNWALL NY
12518-1554
US

V. Phone/Fax

Practice location:
  • Phone: 845-542-6700
  • Fax:
Mailing address:
  • Phone: 845-542-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number005339
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: