Healthcare Provider Details

I. General information

NPI: 1669572731
Provider Name (Legal Business Name): MARY K BOCCARDO RD CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BROAD RD HEALTH EDUCATION DEPT, POB SOUTH, SUITE 1F
SYRACUSE NY
13215-2265
US

IV. Provider business mailing address

4900 BROAD RD
SYRACUSE NY
13215-2265
US

V. Phone/Fax

Practice location:
  • Phone: 315-492-5152
  • Fax: 315-492-5002
Mailing address:
  • Phone: 315-492-5152
  • Fax: 315-492-5002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number918980
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: