Provider Demographics
NPI:1023212164
Name:SACLOLO WELLNESS INSTITUTE
Entity Type:Organization
Organization Name:SACLOLO WELLNESS INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOOGRIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-477-3544
Mailing Address - Street 1:20 W 86TH ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3604
Mailing Address - Country:US
Mailing Address - Phone:212-490-3800
Mailing Address - Fax:212-490-5567
Practice Address - Street 1:20 W 86TH ST STE 1A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3604
Practice Address - Country:US
Practice Address - Phone:212-490-3800
Practice Address - Fax:212-490-5567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199682207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01761628Medicaid
NYG12881Medicare UPIN
NY01761628Medicaid