Provider Demographics
NPI:1578831814
Name:PALACIO, CHRISTINE SUZANNE (OFFICE MANAGER/OWNER)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:SUZANNE
Last Name:PALACIO
Suffix:
Gender:F
Credentials:OFFICE MANAGER/OWNER
Other - Prefix:
Other - First Name:KARL
Other - Middle Name:LUDWIG
Other - Last Name:BOECKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BC-HIS
Mailing Address - Street 1:2297 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3666
Mailing Address - Country:US
Mailing Address - Phone:631-585-1212
Mailing Address - Fax:
Practice Address - Street 1:2297 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE A
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3666
Practice Address - Country:US
Practice Address - Phone:631-585-1212
Practice Address - Fax:631-585-1006
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000001167332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment