Healthcare Provider Details

I. General information

NPI: 1629807813
Provider Name (Legal Business Name): KALAVATHI MANJUNATHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15050 14TH RD
WHITESTONE NY
11357-2609
US

IV. Provider business mailing address

6111 155TH ST
FLUSHING NY
11367-1234
US

V. Phone/Fax

Practice location:
  • Phone: 718-767-0071
  • Fax:
Mailing address:
  • Phone: 516-713-6193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: