Provider Demographics
NPI:1750800926
Name:NNY HEALTH & WELLNESS LLC
Entity type:Organization
Organization Name:NNY HEALTH & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:315-775-8379
Mailing Address - Street 1:21011 STORRS RD
Mailing Address - Street 2:
Mailing Address - City:SACKETS HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:13685-3172
Mailing Address - Country:US
Mailing Address - Phone:720-771-6691
Mailing Address - Fax:
Practice Address - Street 1:21011 STORRS RD
Practice Address - Street 2:
Practice Address - City:SACKETS HARBOR
Practice Address - State:NY
Practice Address - Zip Code:13685-3172
Practice Address - Country:US
Practice Address - Phone:315-775-8379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008768133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty