Provider Demographics
NPI:1356004956
Name:MINT HEALTH NY LLC
Entity Type:Organization
Organization Name:MINT HEALTH NY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, MEMBER, MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIJAI
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-259-5975
Mailing Address - Street 1:41 SAINT NICHOLAS TER APT 54
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-2739
Mailing Address - Country:US
Mailing Address - Phone:646-259-5975
Mailing Address - Fax:
Practice Address - Street 1:41 SAINT NICHOLAS TER APT 54
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-2739
Practice Address - Country:US
Practice Address - Phone:646-259-5975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Single Specialty