Provider Demographics
NPI:1366930836
Name:AGEWELL DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:AGEWELL DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HERBRICH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:516-488-8808
Mailing Address - Street 1:1999 MARCUS AVENUE
Mailing Address - Street 2:SUITE M15
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-488-8808
Mailing Address - Fax:516-488-8808
Practice Address - Street 1:1999 MARCUS AVENUE
Practice Address - Street 2:SUITE M15
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-488-8808
Practice Address - Fax:516-488-8808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015532-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty