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General NPI Number Information
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NPI Number | 1013063528
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Entity Type | Organization
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Legal Business Name | REGO PARK CHIROPRACTIC PC
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 11/20/2008
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Provider Practice Location Address
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Address Line | 6298 WOODHAVEN BLVD
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City | REGO PARK
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State | NY
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Zip | 11374-3738
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Country | US
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Telephone | 718-803-2300
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Fax | 718-565-2875
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Provider Business Mailing Address
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Address Line | 6298 WOODHAVEN BLVD
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City | REGO PARK
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State | NY
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Zip | 11374-3738
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Country | US
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Telephone | 718-803-2300
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Fax | 718-565-2875
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Authorized Official
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Title or Position | PRES
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Name | DR. DIANE M RENZULLI
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Credential | DC
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Telephone | 718-803-2300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | X004316-1
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License Number State | NY
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