Healthcare Provider Details

I. General information

NPI: 1992880421
Provider Name (Legal Business Name): RICARDO CESAR VACCA MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 W 86TH ST
NEW YORK NY
10024-4018
US

IV. Provider business mailing address

48-17 39ST 1ST FLOOR
LONG ISLAND CITY NY
11104
US

V. Phone/Fax

Practice location:
  • Phone: 212-362-8755
  • Fax:
Mailing address:
  • Phone: 347-724-1795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number112932-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: