Healthcare Provider Details

I. General information

NPI: 1053588988
Provider Name (Legal Business Name): UNDER 21
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 W 41ST
NEW YORK NY
10036
US

IV. Provider business mailing address

460 W 41ST
NEW YORK NY
10036
US

V. Phone/Fax

Practice location:
  • Phone: 212-613-0300
  • Fax: 212-268-2832
Mailing address:
  • Phone: 212-613-0300
  • Fax: 212-268-2832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DAVID J DAVIS
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 212-613-0300