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General NPI Number Information
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NPI Number | 1053378067
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Entity Type | Individual
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Provider Name | DOMINICK A DESTEFANO A.T.,C
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Gender | Male
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Dates
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Enumeration Date | 04/26/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1370A MAJORS PATH
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City | SOUTHAMPTON
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State | NY
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Zip | 11968-2416
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Country | US
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Telephone | 631-259-0400
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Fax | 631-259-0404
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Provider Business Mailing Address
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Address Line | 58 SCHOOL ST
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City | HAMPTON BAYS
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State | NY
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Zip | 11946-2657
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Country | US
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Telephone | 631-723-1041
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 000572-1
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License Number State | NY
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