Healthcare Provider Details

I. General information

NPI: 1245920099
Provider Name (Legal Business Name): MED WELLNESS DIAGNOSTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 STATE ST STE 804
ALBANY NY
12207-2524
US

IV. Provider business mailing address

54 STATE ST STE 804
ALBANY NY
12207-2524
US

V. Phone/Fax

Practice location:
  • Phone: 833-294-6969
  • Fax:
Mailing address:
  • Phone: 833-294-6969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: LATISHA MYRIE
Title or Position: CEO
Credential:
Phone: 833-294-6969