Provider Demographics
NPI:1083623409
Name:BE WELL PRIMARY HEALTH CARE CENTER, LLC
Entity Type:Organization
Organization Name:BE WELL PRIMARY HEALTH CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:YEVGENIY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPANKOVSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-434-0711
Mailing Address - Street 1:3007 FARRAGUT ROAD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-2549
Mailing Address - Country:US
Mailing Address - Phone:718-434-0711
Mailing Address - Fax:718-434-0712
Practice Address - Street 1:3007 FARRAGUT ROAD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-2549
Practice Address - Country:US
Practice Address - Phone:718-434-0711
Practice Address - Fax:718-434-0712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7001111R261QM1300X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02528912Medicaid
NYWEL281Medicare ID - Type UnspecifiedGROUP ID