Provider Demographics
NPI:1154055143
Name:SOMA VITA PHYSIO & WELLNESS LLC
Entity Type:Organization
Organization Name:SOMA VITA PHYSIO & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMITRAKAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-591-5544
Mailing Address - Street 1:153 OLD STIRLING RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-5829
Mailing Address - Country:US
Mailing Address - Phone:516-591-5544
Mailing Address - Fax:
Practice Address - Street 1:775 MOUNTAIN BLVD STE 108
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-6262
Practice Address - Country:US
Practice Address - Phone:516-591-5544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy