Healthcare Provider Details

I. General information

NPI: 1184752941
Provider Name (Legal Business Name): BONNIE KIM GOLDBERG RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HICKSVILLE RD SUITE 104
SEAFORD NY
11783-1300
US

IV. Provider business mailing address

850 HICKSVILLE RD SUITE 104
SEAFORD NY
11783-1300
US

V. Phone/Fax

Practice location:
  • Phone: 516-798-0141
  • Fax: 516-798-0694
Mailing address:
  • Phone: 516-798-0141
  • Fax: 516-798-0694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number000872-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: