MEDICARE: SOLE WELLNESS & AESTHETICS, 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	213E00000X	Podiatrist

General Provider Information

NPI Number	:	1760916936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOLE WELLNESS & AESTHETICS, LLC

Provider Business Mailing Address
First Line	:	3221 ROUTE 38 STE 102
Second Line	:
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-9765
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3221 ROUTE 38 STE 102
Second Line	:
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-9765
Country	:	US
Telephone Number	:	732-305-0891
Fax Number	:	732-510-5236

Authorized Official
Title or Position	:	OWNER
Name	:	DANIAL KHALIFA
Credential	:	DPM
Telephone Number	:	732-425-7772

Provider Enumeration Date	:	04/14/2017
Last Update Date	:	12/06/2024

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