Provider Demographics
NPI:1740924687
Name:IM SO YOGA
Entity type:Organization
Organization Name:IM SO YOGA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:8YR YOGA INSTRUCTOR
Authorized Official - Phone:862-236-3376
Mailing Address - Street 1:15 WARREN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-3089
Mailing Address - Country:US
Mailing Address - Phone:973-495-5255
Mailing Address - Fax:
Practice Address - Street 1:1186 RAYMOND BLVD FL 4
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-4108
Practice Address - Country:US
Practice Address - Phone:862-236-3376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305S00000XManaged Care OrganizationsPoint of Service