MEDICARE: GOLDEN HOLISTIC TREATMENT CENTER

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	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1407342728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN HOLISTIC TREATMENT CENTER

Provider Business Mailing Address
First Line	:	6809 BERGENLINE AVE
Second Line	:
City	:	WEST NEW YORK
State	:	NJ
Zip	:	07093-1807
Country	:	US
Telephone Number	:	201-766-0015
Fax Number	:	201-766-0019

Provider Business Practice Location Address
First Line	:	6809 BERGENLINE AVE
Second Line	:
City	:	WEST NEW YORK
State	:	NJ
Zip	:	07093-1807
Country	:	US
Telephone Number	:	201-766-0015
Fax Number	:	201-766-0019

Authorized Official
Title or Position	:	OWNER
Name	:	SOO EO
Credential	:
Telephone Number	:	201-450-2195

Provider Enumeration Date	:	07/10/2018
Last Update Date	:	07/10/2018

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