Healthcare Provider Details

I. General information

NPI: 1184158735
Provider Name (Legal Business Name): CARL BEVILACQUA III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215D WOODCREST DR APT 215D
MODENA NY
12548-5107
US

IV. Provider business mailing address

215D WOODCREST DR APT 215D
MODENA NY
12548-5107
US

V. Phone/Fax

Practice location:
  • Phone: 518-586-6993
  • Fax:
Mailing address:
  • Phone: 518-586-6993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number029970
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: