1548251218 NPI number — QUEENS REPLACEMENT LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548251218 NPI number — QUEENS REPLACEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUEENS REPLACEMENT 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:
KEW GARDENS DIALYSIS CENTER
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:
1548251218
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
97 NEW DORP LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10306-2364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-448-5641
Provider Business Mailing Address Fax Number:
718-876-5969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12046 QUEENS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEW GARDENS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11415-1204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-793-3341
Provider Business Practice Location Address Fax Number:
718-268-1666
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LICCIARDI
Authorized Official First Name:
DOMINIC
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
718-987-5942

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  7003264R , 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: 02718005 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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