Healthcare Provider Details

I. General information

NPI: 1457593964
Provider Name (Legal Business Name): VIJI WELLNESS SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 LARCHMONT WAY
MOUNTAIN TOP PA
18707-2050
US

IV. Provider business mailing address

PO BOX 1388
KINGSTON PA
18704-0388
US

V. Phone/Fax

Practice location:
  • Phone: 570-574-9736
  • Fax:
Mailing address:
  • Phone: 570-288-8881
  • Fax: 570-288-8065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD070171L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD070171L
License Number StatePA

VIII. Authorized Official

Name: RAJAMANICKAM NATARAJAN
Title or Position: PHYSICIAN
Credential: MD
Phone: 570-574-9736