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General NPI Number Information
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NPI Number | 1700471158
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Entity Type | Organization
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Legal Business Name | ALTERNATIVE AGING & MEDISPA
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Dates
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Enumeration Date | 03/08/2021
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Last Update Date | 03/08/2021
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Provider Practice Location Address
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Address Line | 1388 COSGROVE ST
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City | WATERTOWN
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State | NY
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Zip | 13601-4544
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Country | US
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Telephone | 315-777-2749
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Fax |
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Provider Business Mailing Address
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Address Line | 1388 COSGROVE ST
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City | WATERTOWN
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State | NY
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Zip | 13601-4544
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Country | US
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Telephone | 315-777-2749
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Fax |
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | PHYL MCKINNEY
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Credential | FNP-BC
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Telephone | 315-777-2749
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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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