=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154953800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIUMCBT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2020
-----------------------------------------------------
Last Update Date | 01/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 W HUDSON AVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-408-4487
-----------------------------------------------------
Fax | 800-352-3015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 W HUDSON AVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-408-4487
-----------------------------------------------------
Fax | 800-352-3015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MD
-----------------------------------------------------
Name | WEI WANG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-682-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------