Provider Demographics
NPI:1083071757
Name:VIVERITO, CALLIE (MSOM L AC)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:
Last Name:VIVERITO
Suffix:
Gender:F
Credentials:MSOM L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 GORMLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-3010
Mailing Address - Country:US
Mailing Address - Phone:516-945-5944
Mailing Address - Fax:
Practice Address - Street 1:1416 JERUSALEM AVE
Practice Address - Street 2:
Practice Address - City:NORTH MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-1305
Practice Address - Country:US
Practice Address - Phone:516-945-5944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
NY005683171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty