1679561112 NPI number — BROAD CHANNEL VOLUNTEERS INC

Table of content: (NPI 1679561112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679561112 NPI number — BROAD CHANNEL VOLUNTEERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROAD CHANNEL VOLUNTEERS 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:
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:
1679561112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 290184
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WETHERSFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06129-0184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-452-8191
Provider Business Mailing Address Fax Number:
860-721-6362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 NOEL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROAD CHANNEL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11693-1037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-474-6888
Provider Business Practice Location Address Fax Number:
718-474-6888
Provider Enumeration Date:
10/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GENTILE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED AGENT
Authorized Official Telephone Number:
800-452-8191

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  7340 , 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: 01668060 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1679561112 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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