1033611736 NPI number — THE W GROUP AT NEW BROADVIEW, LLC

Table of content: (NPI 1033611736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033611736 NPI number — THE W GROUP AT NEW BROADVIEW, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE W GROUP AT NEW BROADVIEW, 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:
NEW BROADVIEW MANOR HOME FOR ADULTS
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:
1033611736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2357 60TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11204-2689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-840-3355
Provider Business Mailing Address Fax Number:
347-436-8045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 FATHER CAPODANNO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10305-4803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-840-3355
Provider Business Practice Location Address Fax Number:
347-436-8045
Provider Enumeration Date:
03/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GRAJALES
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
PROJECT MANAGER
Authorized Official Telephone Number:
718-840-3355

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  2670L001 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X , with the licence number: 610-F-067 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 311ZA0620X , with the licence number: 610-F-067 , 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)





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