Provider Demographics
NPI:1437705712
Name:MENARDY MENTAL & BODY FITNESS
Entity type:Organization
Organization Name:MENARDY MENTAL & BODY FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTLE
Authorized Official - Middle Name:GWENDOYLYN
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-866-0635
Mailing Address - Street 1:120 N MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-3748
Mailing Address - Country:US
Mailing Address - Phone:845-634-4735
Mailing Address - Fax:845-708-5010
Practice Address - Street 1:120 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-3748
Practice Address - Country:US
Practice Address - Phone:845-634-4735
Practice Address - Fax:845-708-5010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02916645Medicaid