Provider Demographics
NPI:1215650379
Name:LEVIATHAN WELLNESS PLLC
Entity type:Organization
Organization Name:LEVIATHAN WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-612-7485
Mailing Address - Street 1:1584 86TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-3433
Mailing Address - Country:US
Mailing Address - Phone:718-621-5800
Mailing Address - Fax:
Practice Address - Street 1:55 E OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4293
Practice Address - Country:US
Practice Address - Phone:516-987-6428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical