Healthcare Provider Details

I. General information

NPI: 1457306680
Provider Name (Legal Business Name): TOTAL HEALTH AT LICH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HENRY ST
BROOKLYN NY
11201-6001
US

IV. Provider business mailing address

350 HENRY ST
BROOKLYN NY
11201-6001
US

V. Phone/Fax

Practice location:
  • Phone: 516-569-0696
  • Fax: 516-569-3677
Mailing address:
  • Phone: 516-569-0696
  • Fax: 516-569-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN WONG
Title or Position: GROUP MANAGER
Credential: MD
Phone: 718-780-2777