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General NPI Number Information
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NPI Number | 1730463183
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Entity Type | Organization
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Legal Business Name | CHUNGDAM WELLNESS GROUP,INC
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Dates
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Enumeration Date | 10/04/2011
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Last Update Date | 10/04/2011
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Provider Practice Location Address
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Address Line | 315 5TH AVE STE 1001
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City | NEW YORK
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State | NY
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Zip | 10016-6510
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Country | US
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Telephone | 212-685-1004
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Fax | 212-685-1007
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Provider Business Mailing Address
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Address Line | 315 5TH AVE STE 1001
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City | NEW YORK
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State | NY
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Zip | 10016-6510
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Country | US
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Telephone | 212-685-1004
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Fax | 212-685-1007
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. LISA PERSAUD
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Credential | M.D
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Telephone | 212-685-1004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 004553
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 032406
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 254812
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License Number State | NY
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