Basic Information
| Provider Information | |||||||||
| NPI: | 1750926259 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLNIVATORS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 WYNGATE DR E | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115801404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162449904 | ||||||||
| FaxNumber: | 7187631203 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 S MAIN ST UNIT 352 | ||||||||
| Address2: | |||||||||
| City: | NEW CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109563353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444828677 | ||||||||
| FaxNumber: | 7187631203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2019 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | JASMINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5162449904 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 207RH0002X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
No ID Information.