Healthcare Provider Details

I. General information

NPI: 1780012716
Provider Name (Legal Business Name): 48TH ST HOLISTIC SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2013
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 7TH AVE RM 703
NEW YORK NY
10019-6832
US

IV. Provider business mailing address

723 7TH AVE RM 703
NEW YORK NY
10019-6832
US

V. Phone/Fax

Practice location:
  • Phone: 212-470-0360
  • Fax:
Mailing address:
  • Phone: 212-470-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX0108371
License Number StateNY

VIII. Authorized Official

Name: HEEBAE KONG
Title or Position: MANAGER
Credential:
Phone: 212-470-0360