Healthcare Provider Details

I. General information

NPI: 1518208750
Provider Name (Legal Business Name): WHOLE HEALTHY FAMILY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2013
Last Update Date: 03/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2874 MERRICK RD
BELLMORE NY
11710-5726
US

IV. Provider business mailing address

2874 MERRICK RD
BELLMORE NY
11710-5726
US

V. Phone/Fax

Practice location:
  • Phone: 516-221-1212
  • Fax: 516-221-1292
Mailing address:
  • Phone: 516-221-1212
  • Fax: 516-221-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number193423
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012786
License Number StateNY

VIII. Authorized Official

Name: DR. DANA LYN WALTERS
Title or Position: PRESIDENT
Credential: DC
Phone: 516-221-1212