Healthcare Provider Details

I. General information

NPI: 1427085885
Provider Name (Legal Business Name): NICOLA (NICK) ROSELLI OTR.CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5847 FRANCIS LEWIS BLVD STE 200
OAKLAND GDNS NY
11364-1601
US

IV. Provider business mailing address

5847 FRANCIS LEWIS BLVD STE 200
OAKLAND GDNS NY
11364-1601
US

V. Phone/Fax

Practice location:
  • Phone: 718-454-0842
  • Fax: 718-454-1704
Mailing address:
  • Phone: 718-454-0842
  • Fax: 718-454-1704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number005312-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: