Healthcare Provider Details

I. General information

NPI: 1598181513
Provider Name (Legal Business Name): REBORN FOR NEW LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LIBERTY AVE
BROOKLYN NY
11207-3032
US

IV. Provider business mailing address

400 LIBERTY AVE
BROOKLYN NY
11207-3032
US

V. Phone/Fax

Practice location:
  • Phone: 646-251-1400
  • Fax:
Mailing address:
  • Phone: 646-251-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number150211831
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WILKINS WILLIAMS
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 917-553-0982