Healthcare Provider Details

I. General information

NPI: 1144315870
Provider Name (Legal Business Name): CHITHKALA RAVISHANKAR MS RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. KALA RAVISHANKAR

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 05/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 GLEN COVE AVE
GLEN HEAD NY
11545-1593
US

IV. Provider business mailing address

31 GREEN DR
ROSLYN NY
11576-3208
US

V. Phone/Fax

Practice location:
  • Phone: 516-674-9144
  • Fax: 516-674-4024
Mailing address:
  • Phone: 516-674-9144
  • Fax: 516-674-4024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number004375
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: