MEDICARE: PRIME FITNESS AND WELLNESS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1720805773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME FITNESS AND WELLNESS INC

Provider Business Mailing Address
First Line	:	167 BROOK ST
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-6422
Country	:	US
Telephone Number	:	917-902-8243
Fax Number	:

Provider Business Practice Location Address
First Line	:	167 BROOK ST
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-6422
Country	:	US
Telephone Number	:	917-902-8243
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. EDDIE WONG
Credential	:	PT
Telephone Number	:	917-902-8243

Provider Enumeration Date	:	09/23/2024
Last Update Date	:	09/23/2024

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