Healthcare Provider Details

I. General information

NPI: 1386780963
Provider Name (Legal Business Name): MRS. JANINE VILLEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS JANINE VERDONE

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 MONTAUK HWY
EASTPORT NY
11941-1210
US

IV. Provider business mailing address

390 MONTAUK HWY
EASTPORT NY
11941-1210
US

V. Phone/Fax

Practice location:
  • Phone: 631-325-0800
  • Fax:
Mailing address:
  • Phone: 631-325-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number008534-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: