Provider Demographics
NPI:1851764195
Name:VASSALLO, JOHN (LMT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:VASSALLO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SUMMERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-5611
Mailing Address - Country:US
Mailing Address - Phone:631-786-6406
Mailing Address - Fax:631-249-1793
Practice Address - Street 1:535 BROADHOLLOW RD
Practice Address - Street 2:SUITE A-10
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3713
Practice Address - Country:US
Practice Address - Phone:631-396-0447
Practice Address - Fax:631-249-1793
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024075225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist