Healthcare Provider Details

I. General information

NPI: 1972977635
Provider Name (Legal Business Name): THE TOMMY EXPERIENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 E MERRICK RD 2ND FLOOR
VALLEY STREAM NY
11580-5814
US

IV. Provider business mailing address

27 E MERRICK RD 2ND FLOOR
VALLEY STREAM NY
11580-5814
US

V. Phone/Fax

Practice location:
  • Phone: 917-488-3898
  • Fax:
Mailing address:
  • Phone: 917-488-3898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS MICKENS
Title or Position: PRESIDENT CEO
Credential:
Phone: 917-488-3898