=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598181513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REBORN FOR NEW LIFE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2014
-----------------------------------------------------
Last Update Date | 04/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 LIBERTY AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11207-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-251-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 LIBERTY AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11207-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-251-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. WILKINS WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-553-0982
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 150211831
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------