MEDICARE: CHRISTOPHER RIVERA LYNN-LOGUE

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1821358714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER RIVERA LYNN-LOGUE

Provider Business Mailing Address
First Line	:	1296 BAY ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10305-3123
Country	:	US
Telephone Number	:	917-365-1906
Fax Number	:

Provider Business Practice Location Address
First Line	:	2233 NOSTRAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-3045
Country	:	US
Telephone Number	:	718-859-9760
Fax Number	:

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

Provider Enumeration Date	:	05/24/2012
Last Update Date	:	05/24/2012

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