1568619294 NPI number — WEST NASSAU COMMUNITY RESIDENCE

Table of content: (NPI 1568619294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568619294 NPI number — WEST NASSAU COMMUNITY RESIDENCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST NASSAU COMMUNITY RESIDENCE
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:
1568619294
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E OLD COUNTRY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINEOLA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11501-4633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-745-0350
Provider Business Mailing Address Fax Number:
516-877-1305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 ELMONT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMONT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11003-4028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-285-1511
Provider Business Practice Location Address Fax Number:
516-285-0983
Provider Enumeration Date:
08/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VASSALLO
Authorized Official First Name:
MARY ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
516-746-0350

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  9206008 , 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: 01681281 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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