Provider Demographics
NPI:1609475391
Name:ROMEO DISANTILLO, KACY
Entity Type:Individual
Prefix:
First Name:KACY
Middle Name:
Last Name:ROMEO DISANTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT ROYAL
Mailing Address - State:NJ
Mailing Address - Zip Code:08061-1016
Mailing Address - Country:US
Mailing Address - Phone:856-534-2935
Mailing Address - Fax:
Practice Address - Street 1:2000 SHORE RD STE 104
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-2100
Practice Address - Country:US
Practice Address - Phone:609-904-5627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist