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General NPI Number Information
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NPI Number | 1497240683
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Entity Type | Organization
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Legal Business Name | SHINING LIGHT FAMILY HEALTH NP PC
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Dates
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Enumeration Date | 06/29/2018
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Last Update Date | 08/08/2018
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Provider Practice Location Address
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Address Line | 1030 SHERIDAN AVE
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City | BRONX
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State | NY
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Zip | 10456
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Country | US
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Telephone | 516-971-1824
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Fax |
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Provider Business Mailing Address
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Address Line | 5030 BROADWAY STE 818
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City | NEW YORK
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State | NY
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Zip | 10034-1670
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Country | US
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Telephone | 212-567-4931
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | LIDIA VIRGIL
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Credential |
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Telephone | 516-971-1824
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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