Provider Demographics
NPI:1689481947
Name:MODERN TRADITIONS WELLNESS
Entity type:Organization
Organization Name:MODERN TRADITIONS WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:WHITELY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:516-200-5249
Mailing Address - Street 1:333 GLEN HEAD RD STE 155
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1945
Mailing Address - Country:US
Mailing Address - Phone:516-200-5249
Mailing Address - Fax:
Practice Address - Street 1:333 GLEN HEAD RD STE 155
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-1945
Practice Address - Country:US
Practice Address - Phone:516-200-5249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty