1700800406 NPI number — LSR ADVANCED MEDICAL CARE PLLC

Table of content: DR. JERAL KEILSHA DENNIS D.C. (NPI 1730362393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700800406 NPI number — LSR ADVANCED MEDICAL CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LSR ADVANCED MEDICAL CARE PLLC
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:
1700800406
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7612 BAY PKWY
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11214-1516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-368-2200
Provider Business Mailing Address Fax Number:
718-368-0400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7612 BAY PKWY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11214-1516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-368-2200
Provider Business Practice Location Address Fax Number:
718-368-0400
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REPNINA
Authorized Official First Name:
LARISA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
718-368-2200

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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