Healthcare Provider Details

I. General information

NPI: 1770115529
Provider Name (Legal Business Name): PHMD & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1084 MAIN AVE
CLIFTON NJ
07011-2330
US

IV. Provider business mailing address

1084 MAIN AVE
CLIFTON NJ
07011-2330
US

V. Phone/Fax

Practice location:
  • Phone: 914-376-6100
  • Fax: 914-470-5056
Mailing address:
  • Phone: 914-376-6100
  • Fax: 914-470-5056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MARVELL SCOTT
Title or Position: OWNER
Credential:
Phone: 917-501-1747