Healthcare Provider Details

I. General information

NPI: 1770118333
Provider Name (Legal Business Name): 525 WHEAT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WHEATFIELD ST
NORTH TONAWANDA NY
14120-7034
US

IV. Provider business mailing address

525 WHEATFIELD ST
NORTH TONAWANDA NY
14120-7034
US

V. Phone/Fax

Practice location:
  • Phone: 716-462-6353
  • Fax:
Mailing address:
  • Phone: 716-462-6353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH HANULA
Title or Position: NUTRITION SPECIALIST
Credential: AASDN
Phone: 716-462-6353