Provider Demographics
NPI:1306298419
Name:VILLALTA, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:VILLALTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-4534
Mailing Address - Country:US
Mailing Address - Phone:516-609-3100
Mailing Address - Fax:516-609-0671
Practice Address - Street 1:717 FRONT ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4534
Practice Address - Country:US
Practice Address - Phone:516-609-3100
Practice Address - Fax:516-609-0671
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012840111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY012840OtherLICENCE