Healthcare Provider Details

I. General information

NPI: 1629323704
Provider Name (Legal Business Name): MRS. ANGELINA ADINA RIBACOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24302 NORTHERN BLVD
DOUGLASTON NY
11362-1150
US

IV. Provider business mailing address

405 DAUB AVE
HEWLETT NY
11557-1136
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-6200
  • Fax:
Mailing address:
  • Phone: 516-295-1626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: