=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366791444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1ST CHOICE MEDICAL MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2012
-----------------------------------------------------
Last Update Date | 09/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 WEST HAWTHORNE AVE SUITE 22
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-812-8844
-----------------------------------------------------
Fax | 888-218-9150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 WEST HAWTHORNE AVE SUITE 22
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-812-8844
-----------------------------------------------------
Fax | 888-218-9150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TRINETTE GORMEZANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-812-8844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------