Provider Demographics
NPI:1033974522
Name:WALES CLINIC CENTER LLC
Entity Type:Organization
Organization Name:WALES CLINIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-224-5270
Mailing Address - Street 1:538 WALES AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-4510
Mailing Address - Country:US
Mailing Address - Phone:347-716-3865
Mailing Address - Fax:347-716-3864
Practice Address - Street 1:538 WALES AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4510
Practice Address - Country:US
Practice Address - Phone:347-716-3865
Practice Address - Fax:347-716-3864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty