Healthcare Provider Details

I. General information

NPI: 1396297032
Provider Name (Legal Business Name): GAETANO PITTALA LAC, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 ECHO AVE
MOUNT SINAI NY
11766-2000
US

IV. Provider business mailing address

110 TUDOR LN
MIDDLE ISLAND NY
11953-1362
US

V. Phone/Fax

Practice location:
  • Phone: 631-476-4855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number007415
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number022230
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: