Healthcare Provider Details

I. General information

NPI: 1750800926
Provider Name (Legal Business Name): NNY HEALTH & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 09/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21011 STORRS RD
SACKETS HARBOR NY
13685-3172
US

IV. Provider business mailing address

21011 STORRS RD
SACKETS HARBOR NY
13685-3172
US

V. Phone/Fax

Practice location:
  • Phone: 315-775-8379
  • Fax:
Mailing address:
  • Phone: 720-771-6691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number008768
License Number StateNY

VIII. Authorized Official

Name: SUSAN KIM
Title or Position: OWNER/DIETITIAN
Credential: RD
Phone: 315-775-8379