Healthcare Provider Details

I. General information

NPI: 1609930783
Provider Name (Legal Business Name): LIFES BOUNTY MEDICAL CARE P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 RICHMOND RD
STATEN ISLAND NY
10306-2578
US

IV. Provider business mailing address

96 MIDLAND RD
STATEN ISLAND NY
10308-2918
US

V. Phone/Fax

Practice location:
  • Phone: 718-668-6963
  • Fax:
Mailing address:
  • Phone: 718-668-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number168980
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number168980
License Number StateNY

VIII. Authorized Official

Name: ANNA MARIE SCOPELLITO-OLSEN
Title or Position: DOCTOR
Credential:
Phone: 17186686963