1578955951 NPI number — BRONX LEBANON HOSPITAL LIFE RECOVERY CENTER

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 1578955951 NPI number — BRONX LEBANON HOSPITAL LIFE RECOVERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRONX LEBANON HOSPITAL LIFE RECOVERY CENTER
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:
1578955951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 DIXON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TARRYTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10591-3304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-414-2829
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1285 FULTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10456-3401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-518-3711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
DEMETRIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM ADMINISTRATOR
Authorized Official Telephone Number:
718-518-3736

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  0738591 , 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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