1073889010 NPI number — LIFE QUALITY P.T P.C

Table of content: (NPI 1073889010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073889010 NPI number — LIFE QUALITY P.T P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE QUALITY P.T P.C
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:
Provider Other Organization Name Type Code:
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:
1073889010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11412 BEACH CHANNEL DR
Provider Second Line Business Mailing Address:
SUITE # 6
Provider Business Mailing Address City Name:
ROCKAWAY PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11694-2212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-945-7878
Provider Business Mailing Address Fax Number:
718-945-7879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11412 BEACH CHANNEL DR
Provider Second Line Business Practice Location Address:
SUITE # 6
Provider Business Practice Location Address City Name:
ROCKAWAY PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11694-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-945-7878
Provider Business Practice Location Address Fax Number:
718-945-7879
Provider Enumeration Date:
03/23/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MAHMOUD
Authorized Official First Name:
AHMED
Authorized Official Middle Name:
FEKRY
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
917-573-4309

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  018417 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6696905 . This is a "GHI PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02638580 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: MA8417 . This is a "ATLANTIS/EASY CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1000065520 . This is a "AFFINITY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10210162 . This is a "AMERIGROUP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 092282 . This is a "GHI HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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