Healthcare Provider Details

I. General information

NPI: 1659701902
Provider Name (Legal Business Name): PEARLS OF WISDOMOTB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2013
Last Update Date: 11/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 ORANGE ST
BUFFALO NY
14204-1219
US

IV. Provider business mailing address

76 ORANGE ST
BUFFALO NY
14204-1219
US

V. Phone/Fax

Practice location:
  • Phone: 716-856-0360
  • Fax:
Mailing address:
  • Phone: 716-856-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. CYNTHIA ANN FELDER
Title or Position: VICE PRESIDENT
Credential: RN
Phone: 716-573-4290