Healthcare Provider Details

I. General information

NPI: 1477855757
Provider Name (Legal Business Name): BROOKLYN ANTI AGING CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 11/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 64TH ST
BROOKLYN NY
11220-4753
US

IV. Provider business mailing address

745 64TH ST
BROOKLYN NY
11220-4753
US

V. Phone/Fax

Practice location:
  • Phone: 718-517-0665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SORANG KIM
Title or Position: PRESIDENT
Credential:
Phone: 718-517-0665