1770529026 NPI number — BANG AWARENESS ALCOHOL PREVENTION

Table of content: (NPI 1770529026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770529026 NPI number — BANG AWARENESS ALCOHOL PREVENTION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BANG AWARENESS ALCOHOL PREVENTION
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:
MCCONNEGHEY BANG & CORP INC
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:
1770529026
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:
1138 E 229TH ST DRIVE SOUTH AVE
Provider Second Line Business Mailing Address:
6G
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-239-5729
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1075 UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
STADIUM STATION 524525
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-220-7578
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCONNEGHEY
Authorized Official First Name:
MARITZA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXEC OFFICER
Authorized Official Telephone Number:
917-239-5729

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  I069 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QC1500X , with the licence number: 5292 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 02799640 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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