=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962537274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARILYN TUCKER VISELLI MS RD CDN INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 LOCKWOOD AVE SUITE 107
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-632-1896
-----------------------------------------------------
Fax | 914-632-4284
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 LOCKWOOD AVE SUITE 107
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-632-1896
-----------------------------------------------------
Fax | 914-632-4284
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. MARILYN TUCKER VISELLI
-----------------------------------------------------
Credential | MS RD CDN
-----------------------------------------------------
Telephone | 914-282-6801
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | 0007832
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------