Basic Information
| Provider Information | |||||||||
| NPI: | 1609930783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFES BOUNTY MEDICAL CARE P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 96 MIDLAND RD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103082918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186686963 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1776 RICHMOND RD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103062578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186686963 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 12/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | SCOPELLITO-OLSEN | ||||||||
| AuthorizedOfficialFirstName: | ANNA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 17186686963 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 168980 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 168980 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.