MEDICARE: DAVE SMALL LPN

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	164W00000X	Licensed Practical Nurse	284092	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	284092	OTHER	NY	LPN LICENSE

General Provider Information

NPI Number	:	1710209267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVE SMALL LPN

Provider Business Mailing Address
First Line	:	664 E 77TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-3316
Country	:	US
Telephone Number	:	954-806-1140
Fax Number	:

Provider Business Practice Location Address
First Line	:	664 E 77TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-3316
Country	:	US
Telephone Number	:	954-806-1140
Fax Number	:

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

Provider Enumeration Date	:	02/25/2010
Last Update Date	:	02/25/2010

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Directions to “ DAVE SMALL LPN” Practice Location

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