1750538054 NPI number — NESCONSET ACQUISITION LLC

Table of content: (NPI 1750538054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750538054 NPI number — NESCONSET ACQUISITION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NESCONSET ACQUISITION LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MIDDLE ISLAND ADHS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750538054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 SOUTHERN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NESCONSET
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11767-1749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-361-8800
Provider Business Mailing Address Fax Number:
631-361-9528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 ROCKY POINT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLE ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11953-1218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-924-0700
Provider Business Practice Location Address Fax Number:
631-924-0894
Provider Enumeration Date:
08/19/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HEPPENHEIMER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
631-361-8800

Provider Taxonomy Codes

  • Taxonomy code: 311Z00000X , with the licence number:  5157315N , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X , with the licence number: 5157507N , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00848751 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".