Healthcare Provider Details

I. General information

NPI: 1821762154
Provider Name (Legal Business Name): RICARDO GUZMAN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MAIN ST STE B
GOSHEN NY
10924-1636
US

IV. Provider business mailing address

301 MAIN ST STE B
GOSHEN NY
10924-1636
US

V. Phone/Fax

Practice location:
  • Phone: 845-458-8661
  • Fax: 845-615-9456
Mailing address:
  • Phone: 845-458-8661
  • Fax: 845-615-9456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: