Provider Demographics
NPI:1336434273
Name:BOZENKO, NICHOLAS (LAC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BOZENKO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MILES AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 MILES AVE
Practice Address - Street 2:
Practice Address - City:ALBERTSON
Practice Address - State:NY
Practice Address - Zip Code:11507-1607
Practice Address - Country:US
Practice Address - Phone:516-741-2605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2011-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004139-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist