Healthcare Provider Details

I. General information

NPI: 1588936603
Provider Name (Legal Business Name): ELISA CUETO PERMANENT LICENCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2012
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6305 252ND ST
LITTLE NECK NY
11362-2305
US

IV. Provider business mailing address

6305 252ND ST
LITTLE NECK NY
11362-2305
US

V. Phone/Fax

Practice location:
  • Phone: 516-406-6654
  • Fax:
Mailing address:
  • Phone: 516-406-6654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number246541031
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: