Provider Demographics
NPI:1386677508
Name:SUTTON HOLISTIC LLC
Entity Type:Organization
Organization Name:SUTTON HOLISTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:SERGEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ILIYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-724-0900
Mailing Address - Street 1:749 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-7813
Mailing Address - Country:US
Mailing Address - Phone:718-724-0900
Mailing Address - Fax:
Practice Address - Street 1:329 E 52ND ST APT A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-6330
Practice Address - Country:US
Practice Address - Phone:212-319-4798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI09912Medicare UPIN
NY256AXIMedicare ID - Type Unspecified