Healthcare Provider Details

I. General information

NPI: 1407121098
Provider Name (Legal Business Name): RENALD PAUL CDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 VAN PELT AVE
STATEN ISLAND NY
10303-2410
US

IV. Provider business mailing address

187 VAN PELT AVE
STATEN ISLAND NY
10303-2410
US

V. Phone/Fax

Practice location:
  • Phone: 718-448-0363
  • Fax: 718-448-0363
Mailing address:
  • Phone: 718-448-0363
  • Fax: 718-448-0363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number04260
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: