MEDICARE: MRS. ANN FAICCO RDCDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	720814

General Provider Information

NPI Number	:	1003941345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANN FAICCO RDCDN

Provider Business Mailing Address
First Line	:	10 BRADLEY DR
Second Line	:
City	:	NEW CITY
State	:	NY
Zip	:	10956
Country	:	US
Telephone Number	:	845-634-1567
Fax Number	:	201-634-5385

Provider Business Practice Location Address
First Line	:	223 NORTH VAN DIEN AVENUE
Second Line	:
City	:	RIDGEWOOD
State	:	NJ
Zip	:	07450-2736
Country	:	US
Telephone Number	:	201-634-5355
Fax Number	:	201-634-5385

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	07/08/2007

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