=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174884902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSALIE FAVUZZA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2012
-----------------------------------------------------
Last Update Date | 06/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7121 AVENUE V
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11234-6238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-393-0518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7121 AVENUE V
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11234-6238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-393-0518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROSALIE FAVUZZA
-----------------------------------------------------
Credential | M.S.ED.
-----------------------------------------------------
Telephone | 347-393-0518
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------