Provider Demographics
NPI:1831961796
Name:REFINED MEDICAL WELLNESS, PLLC
Entity type:Organization
Organization Name:REFINED MEDICAL WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NYCHOLLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVILANES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-704-7447
Mailing Address - Street 1:3400 NESCONSET HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3400 NESCONSET HWY STE 104
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3327
Practice Address - Country:US
Practice Address - Phone:516-704-7447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center