Healthcare Provider Details

I. General information

NPI: 1881982700
Provider Name (Legal Business Name): MARIEZZ EYSMAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 THORMAN AVE
HICKSVILLE NY
11801-1342
US

IV. Provider business mailing address

79 THORMAN AVE
HICKSVILLE NY
11801-1342
US

V. Phone/Fax

Practice location:
  • Phone: 516-681-1381
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number016994
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: