Provider Demographics
NPI:1760717722
Name:VALERIO, WILTON (MSTOM, LAC)
Entity Type:Individual
Prefix:
First Name:WILTON
Middle Name:
Last Name:VALERIO
Suffix:
Gender:M
Credentials:MSTOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W 168TH ST APT 5B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-4117
Mailing Address - Country:US
Mailing Address - Phone:646-842-0420
Mailing Address - Fax:
Practice Address - Street 1:305 2ND AVE STE 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2746
Practice Address - Country:US
Practice Address - Phone:646-842-0420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003979171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist