Provider Demographics
NPI:1902332588
Name:11 MEDICAL DRIVE WELLNESS PLLC
Entity Type:Organization
Organization Name:11 MEDICAL DRIVE WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-805-6384
Mailing Address - Street 1:11 MEDICAL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1589
Mailing Address - Country:US
Mailing Address - Phone:631-509-6066
Mailing Address - Fax:631-849-5824
Practice Address - Street 1:11 MEDICAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1589
Practice Address - Country:US
Practice Address - Phone:631-509-6066
Practice Address - Fax:631-849-5824
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DH MANAGEMENT GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty