Healthcare Provider Details

I. General information

NPI: 1447283882
Provider Name (Legal Business Name): DIVERSIFIED SERVICES FOR OCCUPATIONAL THERAPY, PHYSICAL THER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 DELAWARE AVE
KENMORE NY
14217-2309
US

IV. Provider business mailing address

2900 DELAWARE AVE
KENMORE NY
14217-2309
US

V. Phone/Fax

Practice location:
  • Phone: 716-871-9883
  • Fax: 716-871-9887
Mailing address:
  • Phone: 716-871-9883
  • Fax: 716-871-9887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number001149
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number000846
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State

VIII. Authorized Official

Name: DR. SALVATORE GRUTTADAURIA
Title or Position: PRESIDENT-CEO
Credential: AU.D.
Phone: 716-871-9883