Provider Demographics
NPI:1639996762
Name:WALES CLINIC LLC
Entity type:Organization
Organization Name:WALES CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-220-3534
Mailing Address - Street 1:538 WALES AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-4510
Mailing Address - Country:US
Mailing Address - Phone:347-716-3865
Mailing Address - Fax:347-716-3865
Practice Address - Street 1:538 WALES AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4510
Practice Address - Country:US
Practice Address - Phone:347-716-3865
Practice Address - Fax:347-716-3865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty