Provider Demographics
NPI:1932731676
Name:MYRTHIL, CEDRIC
Entity Type:Individual
Prefix:MR
First Name:CEDRIC
Middle Name:
Last Name:MYRTHIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LAURA DR
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-2810
Mailing Address - Country:US
Mailing Address - Phone:917-923-7382
Mailing Address - Fax:
Practice Address - Street 1:100 NICHOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2021-08-04
Deactivation Date:2021-07-21
Deactivation Code:
Reactivation Date:2021-08-03
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer