Provider Demographics
NPI:1417368663
Name:NEMETH, MARY (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NEMETH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 JOHNSON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6081
Mailing Address - Country:US
Mailing Address - Phone:631-588-1700
Mailing Address - Fax:631-588-1705
Practice Address - Street 1:879 JOHNSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-6081
Practice Address - Country:US
Practice Address - Phone:631-588-1700
Practice Address - Fax:631-588-1705
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005054171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist