Healthcare Provider Details

I. General information

NPI: 1235653437
Provider Name (Legal Business Name): FAIRY LICEMOTHERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2463 LONG BEACH RD
OCEANSIDE NY
11572-1362
US

IV. Provider business mailing address

2463 LONG BEACH RD
OCEANSIDE NY
11572-1362
US

V. Phone/Fax

Practice location:
  • Phone: 866-561-0492
  • Fax:
Mailing address:
  • Phone: 866-561-0492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: CAROL MICHELLE GILBERT
Title or Position: PRESIDENT
Credential:
Phone: 516-313-8095