Provider Demographics
NPI:1124635545
Name:CIARDULLI, MICHAEL JR (LMT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CIARDULLI
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 RAAB AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4521
Mailing Address - Country:US
Mailing Address - Phone:619-250-2937
Mailing Address - Fax:
Practice Address - Street 1:174 RAAB AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-4521
Practice Address - Country:US
Practice Address - Phone:619-250-2937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023602225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist