Healthcare Provider Details

I. General information

NPI: 1821301045
Provider Name (Legal Business Name): THE PORT MORRIS WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 E 138TH ST
BRONX NY
10454-1902
US

IV. Provider business mailing address

804 E 138TH ST
BRONX NY
10454-1902
US

V. Phone/Fax

Practice location:
  • Phone: 718-665-7500
  • Fax: 718-665-4768
Mailing address:
  • Phone: 718-665-7500
  • Fax: 718-665-4768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number00214
License Number StateNY

VIII. Authorized Official

Name: DR. SARAH CHURCH
Title or Position: DIRECTOR OF OPERATIONS
Credential: MD
Phone: 718-409-9450