Healthcare Provider Details

I. General information

NPI: 1558976696
Provider Name (Legal Business Name): CARLO ACOSTA BSMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 W 51ST ST FL 5
NEW YORK NY
10019-6905
US

IV. Provider business mailing address

1 MELBOURNE RD
GREAT NECK NY
11021-4636
US

V. Phone/Fax

Practice location:
  • Phone: 212-651-7515
  • Fax:
Mailing address:
  • Phone: 917-545-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number010446
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: