MEDICARE: LACEY CAVALLO DPT

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	225100000X	Physical Therapist	0331971	NY

General Provider Information

NPI Number	:	1497281836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY CAVALLO DPT

Provider Business Mailing Address
First Line	:	464 GRAND BLVD
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-1742
Country	:	US
Telephone Number	:	516-330-9213
Fax Number	:

Provider Business Practice Location Address
First Line	:	464 GRAND BLVD
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-1742
Country	:	US
Telephone Number	:	516-330-9213
Fax Number	:

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

Provider Enumeration Date	:	05/04/2017
Last Update Date	:	05/04/2017

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Directions to “ LACEY CAVALLO DPT” Practice Location

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