Healthcare Provider Details

I. General information

NPI: 1316572027
Provider Name (Legal Business Name): REBECCA MOLINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9, 3251 NY-112 #2
MEDFORD NY
11763
US

IV. Provider business mailing address

9, 3251 NY-112 #2
MEDFORD NY
11763
US

V. Phone/Fax

Practice location:
  • Phone: 631-451-6007
  • Fax:
Mailing address:
  • Phone: 631-451-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: