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General NPI Number Information
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NPI Number | 1366690307
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Entity Type | Organization
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Legal Business Name | PRO ACTIVE HEALTH CARE PC MEDICAL
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Dates
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Enumeration Date | 09/03/2008
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Last Update Date | 07/15/2010
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Provider Practice Location Address
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Address Line | 2001 MARCUS AVE SUITE E240
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City | NEW HYDE PARK
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State | NY
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Zip | 11042-1011
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Country | US
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Telephone | 516-502-2308
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Fax | 516-673-4804
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Provider Business Mailing Address
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Address Line | 2001 MARCUS AVE SUITE E240
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City | NEW HYDE PARK
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State | NY
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Zip | 11042-1011
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Country | US
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Telephone | 516-502-2308
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Fax | 516-673-4804
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOCELYN MACASAET CERVANTES
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Credential | M.D.
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Telephone | 516-502-2308
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 182681
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License Number State | NY
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