Healthcare Provider Details

I. General information

NPI: 1801064167
Provider Name (Legal Business Name): FITNESS & RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 LAKE AVE
TUCKAHOE NY
10707-3306
US

IV. Provider business mailing address

150 LAKE AVE
TUCKAHOE NY
10707-3306
US

V. Phone/Fax

Practice location:
  • Phone: 914-395-3691
  • Fax: 914-395-3693
Mailing address:
  • Phone: 914-395-3691
  • Fax: 914-395-3693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number203477
License Number StateNY

VIII. Authorized Official

Name: DR. MACK LEE SULLIVAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 914-395-3691