Healthcare Provider Details

I. General information

NPI: 1134362601
Provider Name (Legal Business Name): AWFULLY BIG ADVENTURE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 E 28TH ST SUITE 1004
NEW YORK NY
10016-8413
US

IV. Provider business mailing address

118 E 28TH ST SUITE 1004
NEW YORK NY
10016-8413
US

V. Phone/Fax

Practice location:
  • Phone: 917-805-0110
  • Fax:
Mailing address:
  • Phone: 917-805-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number726604723
License Number StateNY

VIII. Authorized Official

Name: MS. Z. MIER
Title or Position: MANAGER
Credential:
Phone: 917-805-0110