=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902355704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE V ROTONDI L.AC.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2016
-----------------------------------------------------
Last Update Date | 01/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 872 MIDDLE COUNTRY RD SUITE 5&6
-----------------------------------------------------
City | SAINT JAMES
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11780-3223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-360-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 HAMPTON VISTA DR
-----------------------------------------------------
City | MANORVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11949-2859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-729-8508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 001352
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------