Healthcare Provider Details

I. General information

NPI: 1205335205
Provider Name (Legal Business Name): EILEEN PHOENIX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 CLARKE AVE
STATEN ISLAND NY
10306-1112
US

IV. Provider business mailing address

134 CLARKE AVE
STATEN ISLAND NY
10306-1112
US

V. Phone/Fax

Practice location:
  • Phone: 718-619-6808
  • Fax: 718-667-5365
Mailing address:
  • Phone: 718-619-6808
  • Fax: 718-667-5365

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: EILEEN SUSAN PHOENIX
Title or Position: OWNER
Credential: L.AC.
Phone: 718-619-6808