Healthcare Provider Details

I. General information

NPI: 1477192177
Provider Name (Legal Business Name): KEN KRISTOFER PINO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2019
Last Update Date: 11/27/2023
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 125TH ST
NEW YORK NY
10035-6000
US

IV. Provider business mailing address

187 BERGEN AVE
BERGENFIELD NJ
07621-2438
US

V. Phone/Fax

Practice location:
  • Phone: 646-672-5800
  • Fax:
Mailing address:
  • Phone: 201-742-3155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number694477
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: