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General NPI Number Information
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NPI Number | 1861785149
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Entity Type | Organization
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Legal Business Name | ADVANCE MEDICAL AND DIET SERVICES
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Dates
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Enumeration Date | 05/19/2011
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Last Update Date | 05/19/2011
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Provider Practice Location Address
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Address Line | 3930 RICHMOND AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10312-5104
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Country | US
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Telephone | 718-605-1040
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Fax |
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Provider Business Mailing Address
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Address Line | 3930 RICHMOND AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10312-5104
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EUGENE MANCUSO
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Credential |
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Telephone | 718-605-1040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 166460
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License Number State | NY
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