Healthcare Provider Details

I. General information

NPI: 1467851105
Provider Name (Legal Business Name): MAXIMUM HEALTH & WELLNESS GLENDALE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 OTTO RD
GLENDALE NY
11385-6204
US

IV. Provider business mailing address

6545 OTTO RD
GLENDALE NY
11385-6204
US

V. Phone/Fax

Practice location:
  • Phone: 718-417-7500
  • Fax: 718-417-7501
Mailing address:
  • Phone: 718-417-7500
  • Fax: 718-417-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER R CARROLL
Title or Position: OFFICE REP
Credential:
Phone: 352-942-1204