1073679205 NPI number — FADMO HEALTH AND HOME CARE AGENCY INC

Table of content: (NPI 1073679205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073679205 NPI number — FADMO HEALTH AND HOME CARE AGENCY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FADMO HEALTH AND HOME CARE AGENCY INC
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:
FADMO HEALTH AND ALLIED SCHOOL
Provider Other Organization Name Type Code:
4
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:
1073679205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
194 TARGEE ST
Provider Second Line Business Mailing Address:
ABBY AGBOOLA
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10304-1926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-390-0561
Provider Business Mailing Address Fax Number:
718-390-5166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
194 TARGEE ST
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:
10304-1926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-390-0561
Provider Business Practice Location Address Fax Number:
718-390-5166
Provider Enumeration Date:
12/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AGBOOLA
Authorized Official First Name:
ABBY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
718-390-0561

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  403674-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251J00000X , with the licence number: 403674-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X , with the licence number: 360383-1 , 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: 1343L001 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1343L001 . This is a "CLIA WAIVER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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