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General NPI Number Information
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NPI Number | 1679903470
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Entity Type | Organization
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Legal Business Name | MELVILLE SC, LLC
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Dates
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Enumeration Date | 11/15/2013
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Last Update Date | 11/15/2013
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Provider Practice Location Address
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Address Line | 1895 WALT WHITMAN RD SUITE 10
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City | MELVILLE
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State | NY
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Zip | 11747-3031
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Country | US
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Telephone | 631-293-9700
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Fax | 631-293-2021
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Provider Business Mailing Address
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Address Line | 1895 WALT WHITMAN RD SUITE 10
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City | MELVILLE
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State | NY
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Zip | 11747-3031
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Country | US
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Telephone | 631-293-9700
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Fax | 631-293-2021
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | PROF. DANIEL FORSBERG
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Credential | PA-C
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Telephone | 631-293-9700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 5153209R
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License Number State | NY
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