MEDICARE: CORRESA E WHYTE RD

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	004534-1	NY

General Provider Information

NPI Number	:	1487600854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORRESA E WHYTE RD

Provider Business Mailing Address
First Line	:	430 W MERRICK RD
Second Line	:	STE 16
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-5201
Country	:	US
Telephone Number	:	718-276-0365
Fax Number	:	718-276-4751

Provider Business Practice Location Address
First Line	:	430 W MERRICK RD
Second Line	:	STE 16
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-5201
Country	:	US
Telephone Number	:	516-816-0126
Fax Number	:

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	01/23/2016

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Directions to “ CORRESA E WHYTE RD” Practice Location

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