Healthcare Provider Details

I. General information

NPI: 1366727687
Provider Name (Legal Business Name): MARINA BEDROSSIAN RDN, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2011
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 N WOODHULL RD
HUNTINGTON NY
11743-2826
US

IV. Provider business mailing address

77 N WOODHULL RD
HUNTINGTON NY
11743-2826
US

V. Phone/Fax

Practice location:
  • Phone: 631-374-6371
  • Fax: 631-498-1174
Mailing address:
  • Phone: 631-374-6371
  • Fax: 631-498-1174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1066034
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: