Healthcare Provider Details

I. General information

NPI: 1235849076
Provider Name (Legal Business Name): 315 MADISON WELLNESS MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MADISON AVE RM 901
NEW YORK NY
10017-5427
US

IV. Provider business mailing address

315 MADISON AVE RM 901
NEW YORK NY
10017-5427
US

V. Phone/Fax

Practice location:
  • Phone: 848-565-4819
  • Fax:
Mailing address:
  • Phone: 848-565-4819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNY DONG
Title or Position: OFFICE MANAGER
Credential:
Phone: 848-565-4819