Healthcare Provider Details

I. General information

NPI: 1386677508
Provider Name (Legal Business Name): SUTTON HOLISTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 E 52ND ST APT A
NEW YORK NY
10022-6330
US

IV. Provider business mailing address

749 OCEAN PKWY
BROOKLYN NY
11230-7813
US

V. Phone/Fax

Practice location:
  • Phone: 212-319-4798
  • Fax:
Mailing address:
  • Phone: 718-724-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNY

VIII. Authorized Official

Name: SERGEY ILIYEV
Title or Position: M.D.
Credential:
Phone: 718-724-0900