MEDICARE: NINO ANTONIO VIDAL SARVIDA OT

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	225X00000X	Occupational Therapist	013969-1	NY

General Provider Information

NPI Number	:	1649502188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NINO ANTONIO VIDAL SARVIDA OT

Provider Business Mailing Address
First Line	:	361 EDISON ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-3043
Country	:	US
Telephone Number	:	718-980-0101
Fax Number	:	718-980-1641

Provider Business Practice Location Address
First Line	:	361 EDISON ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-3043
Country	:	US
Telephone Number	:	718-980-0101
Fax Number	:	718-980-1641

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

Provider Enumeration Date	:	02/09/2010
Last Update Date	:	02/09/2010

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