Provider Demographics
NPI:1194302950
Name:MCEVILLEY FOREVER YOUNG WELLNESS, LTD.
Entity type:Organization
Organization Name:MCEVILLEY FOREVER YOUNG WELLNESS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:347-439-4983
Mailing Address - Street 1:50 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-1336
Mailing Address - Country:US
Mailing Address - Phone:347-439-4983
Mailing Address - Fax:
Practice Address - Street 1:50 BROADWAY
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-1336
Practice Address - Country:US
Practice Address - Phone:347-439-4983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-26
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty