Healthcare Provider Details

I. General information

NPI: 1356727382
Provider Name (Legal Business Name): RITA SALLAH LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 MAIN ST
ISLIP NY
11751-3542
US

IV. Provider business mailing address

211 HALSEY MANOR RD
MANORVILLE NY
11949-1609
US

V. Phone/Fax

Practice location:
  • Phone: 631-446-1046
  • Fax: 631-446-1300
Mailing address:
  • Phone: 691-494-8173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number005280-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: