Healthcare Provider Details

I. General information

NPI: 1417319252
Provider Name (Legal Business Name): EMERGE YOGA & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 BROADWAY
MASSAPEQUA NY
11758-5027
US

IV. Provider business mailing address

623 BROADWAY
MASSAPEQUA NY
11758-5027
US

V. Phone/Fax

Practice location:
  • Phone: 516-781-1078
  • Fax:
Mailing address:
  • Phone: 516-781-1078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number021089
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number203931
License Number StateNY

VIII. Authorized Official

Name: JENNIFER C NELSON
Title or Position: OWNER, CFO
Credential: LAC, LMT, RYT
Phone: 516-781-1078