Healthcare Provider Details

I. General information

NPI: 1417057357
Provider Name (Legal Business Name): DIANE J. REPPERT D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W 57TH ST STE 712
NEW YORK NY
10019-2302
US

IV. Provider business mailing address

119 W 57TH ST STE 712
NEW YORK NY
10019-2302
US

V. Phone/Fax

Practice location:
  • Phone: 212-581-9079
  • Fax: 212-581-1413
Mailing address:
  • Phone: 212-581-9079
  • Fax: 212-581-1413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberX004193
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: