Provider Demographics
NPI:1497240683
Name:SHINING LIGHT FAMILY HEALTH NP PC
Entity Type:Organization
Organization Name:SHINING LIGHT FAMILY HEALTH NP PC
Other - Org Name:ADVANCED PREVENTIVE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LIDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRGIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-971-1824
Mailing Address - Street 1:5030 BROADWAY STE 818
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-1670
Mailing Address - Country:US
Mailing Address - Phone:212-567-4931
Mailing Address - Fax:
Practice Address - Street 1:1030 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456
Practice Address - Country:US
Practice Address - Phone:516-971-1824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-29
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty