Provider Demographics
NPI:1164963914
Name:NEW YORK WELLNESS,LLC
Entity Type:Organization
Organization Name:NEW YORK WELLNESS,LLC
Other - Org Name:KOALA CENTER FOR SLEEP DISORDERS NY1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOBILIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-401-0602
Mailing Address - Street 1:11825 STATE ROUTE 40
Mailing Address - Street 2:STE. #100
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8842
Mailing Address - Country:US
Mailing Address - Phone:309-839-9943
Mailing Address - Fax:309-839-9943
Practice Address - Street 1:9 E 45TH ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-2425
Practice Address - Country:US
Practice Address - Phone:212-401-0602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7537010001Medicare PIN