Healthcare Provider Details

I. General information

NPI: 1679242002
Provider Name (Legal Business Name): THE MIA CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 PLATINUM CT STE C
MEDFORD NY
11763-2247
US

IV. Provider business mailing address

12 PLATINUM CT STE C
MEDFORD NY
11763-2247
US

V. Phone/Fax

Practice location:
  • Phone: 631-996-4430
  • Fax:
Mailing address:
  • Phone: 631-996-4430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: KAREN CONSTANCE FIELD
Title or Position: OWNER
Credential: PNP
Phone: 631-996-4430