Healthcare Provider Details

I. General information

NPI: 1508606997
Provider Name (Legal Business Name): SPRING VALLEY WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 ROUTE 59 STE 170
SPRING VALLEY NY
10977-5231
US

IV. Provider business mailing address

400 RELLA BLVD STE 165
SUFFERN NY
10901-8114
US

V. Phone/Fax

Practice location:
  • Phone: 973-747-5217
  • Fax: 973-396-8832
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. LEO ESCOBAR
Title or Position: CREDENTIALING OFFICER
Credential:
Phone: 908-202-5690