MEDICARE: HOLLY VESCOVI

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	172A00000X	Driver	38629	NY

General Provider Information

NPI Number	:	1033573670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY VESCOVI

Provider Business Mailing Address
First Line	:	PO BOX 204
Second Line	:
City	:	EAST MARION
State	:	NY
Zip	:	11939-0204
Country	:	US
Telephone Number	:	631-477-5912
Fax Number	:

Provider Business Practice Location Address
First Line	:	370 ROCKY POINT RD
Second Line	:
City	:	EAST MARION
State	:	NY
Zip	:	11939-1123
Country	:	US
Telephone Number	:	631-477-5912
Fax Number	:

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

Provider Enumeration Date	:	04/10/2016
Last Update Date	:	04/10/2016

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Directions to “ HOLLY VESCOVI ” Practice Location

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