MEDICARE: NINA WACHTEL 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	002320	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P1941384	OTHER	NY	OXFORD

General Provider Information

NPI Number	:	1659420081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NINA WACHTEL RD

Provider Business Mailing Address
First Line	:	400 TITUS WAY
Second Line	:
City	:	EAST WILLISTON
State	:	NY
Zip	:	11596-2539
Country	:	US
Telephone Number	:	516-746-0553
Fax Number	:	516-746-0553

Provider Business Practice Location Address
First Line	:	400 TITUS WAY
Second Line	:
City	:	EAST WILLISTON
State	:	NY
Zip	:	11596-2539
Country	:	US
Telephone Number	:	516-746-0553
Fax Number	:	516-746-0553

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

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/08/2007

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