1871798710 NPI number — 55 SANDALWOOD ENTERPRISES INC

Table of content: (NPI 1871798710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871798710 NPI number — 55 SANDALWOOD ENTERPRISES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
55 SANDALWOOD ENTERPRISES 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:
6
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:
1871798710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
818 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERHEAD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11901-2563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-284-2299
Provider Business Mailing Address Fax Number:
631-284-2305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 BAINBRIDGE AVE
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-920-4333
Provider Business Practice Location Address Fax Number:
718-547-2907
Provider Enumeration Date:
06/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CARR
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
631-284-2299

Provider Taxonomy Codes

  • Taxonomy code: 237600000X , 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: M8W601 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2527580 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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