Provider Demographics
NPI:1831215508
Name:PHOENIX CHIROPRACTIC WELLNESS, PC
Entity type:Organization
Organization Name:PHOENIX CHIROPRACTIC WELLNESS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:DEBORAH
Authorized Official - Last Name:HEREDIA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:516-505-0755
Mailing Address - Street 1:288 HEMPSTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-2039
Mailing Address - Country:US
Mailing Address - Phone:516-505-0755
Mailing Address - Fax:516-505-5353
Practice Address - Street 1:288 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-2039
Practice Address - Country:US
Practice Address - Phone:516-505-0755
Practice Address - Fax:516-505-5353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008050111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWWA141Medicare PIN