Basic Information
| Provider Information | |||||||||
| NPI: | 1063775310 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THERACARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 WESTCHESTER AVENUE | ||||||||
| Address2: | 102 | ||||||||
| City: | NEW YORK CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104613512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185975558 | ||||||||
| FaxNumber: | 7188235494 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 WESTCHESTER AVE | ||||||||
| Address2: | 102 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104613512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185975558 | ||||||||
| FaxNumber: | 7188235494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2012 | ||||||||
| LastUpdateDate: | 06/21/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FUENTES | ||||||||
| AuthorizedOfficialFirstName: | IRIS | ||||||||
| AuthorizedOfficialMiddleName: | N/A | ||||||||
| AuthorizedOfficialTitleorPosition: | SPECIAL INSTRUCTOR | ||||||||
| AuthorizedOfficialTelephone: | 7185975558 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
| AuthorizedOfficialCredential: | MSED | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | 606668 | NY | Y | Agencies | Early Intervention Provider Agency |
No ID Information.