Provider Demographics
NPI:1871981944
Name:DE CICCO, PETER (L AC)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:DE CICCO
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 GOFFLE RD STE 222
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4036
Mailing Address - Country:US
Mailing Address - Phone:201-652-1200
Mailing Address - Fax:
Practice Address - Street 1:555 GOFFLE RD STE 222
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4036
Practice Address - Country:US
Practice Address - Phone:201-652-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-24
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25005389171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist