Healthcare Provider Details

I. General information

NPI: 1750926259
Provider Name (Legal Business Name): CLNIVATORS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 S MAIN ST UNIT 352
NEW CITY NY
10956-3353
US

IV. Provider business mailing address

801 WYNGATE DR E
VALLEY STREAM NY
11580-1404
US

V. Phone/Fax

Practice location:
  • Phone: 844-482-8677
  • Fax: 718-763-1203
Mailing address:
  • Phone: 516-244-9904
  • Fax: 718-763-1203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JASMINE PIERCE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 516-244-9904