Healthcare Provider Details

I. General information

NPI: 1851652887
Provider Name (Legal Business Name): CPW WELLNESS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 CENTRAL PARK W SUITE 1D
NEW YORK NY
10023-6297
US

IV. Provider business mailing address

146 CENTRAL PARK W SUITE 1D
NEW YORK NY
10023-6297
US

V. Phone/Fax

Practice location:
  • Phone: 212-877-1767
  • Fax: 212-877-1971
Mailing address:
  • Phone: 212-877-1767
  • Fax: 212-877-1971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number193423
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number012786
License Number StateNY

VIII. Authorized Official

Name: LIONEL BISSOON
Title or Position: OFFICER
Credential: MD
Phone: 212-877-1767