Provider Demographics
NPI:1184332389
Name:SURICO, STEVEN RYAN (MS, RD, CDN)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:RYAN
Last Name:SURICO
Suffix:
Gender:M
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SADDLE ROCK RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4809
Mailing Address - Country:US
Mailing Address - Phone:631-560-1141
Mailing Address - Fax:
Practice Address - Street 1:211 SADDLE ROCK RD
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4809
Practice Address - Country:US
Practice Address - Phone:631-560-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011086133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty