MEDICARE: GRAND UNION HOLISTIC SOLUTIONS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1003677998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND UNION HOLISTIC SOLUTIONS, LLC

Provider Business Mailing Address
First Line	:	1150 SOUTH AVE STE 200
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3404
Country	:	US
Telephone Number	:	929-487-0003
Fax Number	:

Provider Business Practice Location Address
First Line	:	1150 SOUTH AVE STE 200
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3404
Country	:	US
Telephone Number	:	929-487-0003
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JEFFERY KLEIN
Credential	:
Telephone Number	:	929-487-0003

Provider Enumeration Date	:	01/18/2024
Last Update Date	:	01/18/2024

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