=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629854492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANASHIR RUVINOV FAMILY HEALTH NP PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2023
-----------------------------------------------------
Last Update Date | 10/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 331 KINGS HWY STE A
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11223-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-995-9999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1375 CONEY ISLAND AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230-4166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-545-2292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MANASHIR RUVINOV
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 917-545-2292
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------