Provider Demographics
NPI:1851541858
Name:RENZULLI, DIANE M (DC)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:M
Last Name:RENZULLI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6298 WOODHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3738
Mailing Address - Country:US
Mailing Address - Phone:718-803-2300
Mailing Address - Fax:718-565-2875
Practice Address - Street 1:6298 WOODHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3738
Practice Address - Country:US
Practice Address - Phone:718-803-2300
Practice Address - Fax:718-565-2875
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX004316-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY58574Medicare PIN