1194135467 NPI number — MRS. CAROLINE KAY VIVACQUA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194135467 NPI number — MRS. CAROLINE KAY VIVACQUA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIVACQUA
Provider First Name:
CAROLINE
Provider Middle Name:
KAY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PINA
Provider Other First Name:
CAROLINE
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194135467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 TARRY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEVITTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11756-4026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-284-2602
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 88TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST ELMHURST
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11369-1010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-397-7851
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/07/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  025013 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04307851 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".