Healthcare Provider Details

I. General information

NPI: 1861786840
Provider Name (Legal Business Name): DIAGNOSTIC NEUROLIGICAL TREATMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 HUGUENOT AVE
STATEN ISLAND NY
10312-4312
US

IV. Provider business mailing address

90 MILLS AVE
STATEN ISLAND NY
10305-4524
US

V. Phone/Fax

Practice location:
  • Phone: 718-524-0500
  • Fax:
Mailing address:
  • Phone: 718-524-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number101545
License Number StateNY

VIII. Authorized Official

Name: JOSEPH MORMINO
Title or Position: OWNER
Credential: M.D.
Phone: 718-524-0500