Healthcare Provider Details

I. General information

NPI: 1962312793
Provider Name (Legal Business Name): MAKE HARLEM GREAT AGAIN CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 W 131ST ST # 12
NEW YORK NY
10027-2019
US

IV. Provider business mailing address

245 W 131ST ST
NEW YORK NY
10027-2019
US

V. Phone/Fax

Practice location:
  • Phone: 844-427-5360
  • Fax:
Mailing address:
  • Phone: 844-427-5360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: MR. QUINTIN JEROME BALLENTINE
Title or Position: CEO
Credential:
Phone: 202-995-3133