Provider Demographics
NPI:1376950279
Name:CLASSIC WELLNESS FAMILY MEDICAL PRACTICE LLC
Entity Type:Organization
Organization Name:CLASSIC WELLNESS FAMILY MEDICAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF NURSING PRACTICE, APN
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:OKORO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APN
Authorized Official - Phone:718-753-1721
Mailing Address - Street 1:1220 VICTOR AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-3706
Mailing Address - Country:US
Mailing Address - Phone:718-753-1721
Mailing Address - Fax:
Practice Address - Street 1:1220 VICTOR AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-3706
Practice Address - Country:US
Practice Address - Phone:718-753-1721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00257300207Q00000X, 208D00000X, 261QP2300X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0453951Medicaid