Healthcare Provider Details

I. General information

NPI: 1376695536
Provider Name (Legal Business Name): RICK SHIELDS CDN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13681 71ST ROAD
FLUSHING NY
11367-1942
US

IV. Provider business mailing address

13681 71ST ROAD
FLUSHING NY
11367-1942
US

V. Phone/Fax

Practice location:
  • Phone: 718-544-4036
  • Fax: 718-544-4036
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number000227
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: