Healthcare Provider Details

I. General information

NPI: 1316377534
Provider Name (Legal Business Name): PALLADIA WELLNESS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 3RD AVE
NEW YORK NY
10035-2208
US

IV. Provider business mailing address

2006 MADISON AVE
NEW YORK NY
10035-1217
US

V. Phone/Fax

Practice location:
  • Phone: 212-400-3230
  • Fax: 212-400-3231
Mailing address:
  • Phone: 212-979-8800
  • Fax: 212-979-0100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number8898001A
License Number StateNY

VIII. Authorized Official

Name: MR. MARK HURWITZ
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 212-979-8800