Healthcare Provider Details

I. General information

NPI: 1265962823
Provider Name (Legal Business Name): PREVENTIVE PAIN & WELLNESS OF ARDSLEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 SAW MILL RIVER RD STE LL1
ARDSLEY NY
10502-1048
US

IV. Provider business mailing address

1053 SAW MILL RIVER RD STE LL1
ARDSLEY NY
10502-1048
US

V. Phone/Fax

Practice location:
  • Phone: 914-376-6100
  • Fax: 914-231-6872
Mailing address:
  • Phone: 914-376-6100
  • Fax: 914-231-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA NIELI
Title or Position: BILLING MANAGER
Credential:
Phone: 914-376-6100