Basic Information
| Provider Information | |||||||||
| NPI: | 1174020887 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRONX LEBANON HOSPITAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11100 S RIVER HEIGHTS DR APT B209 | ||||||||
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| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840956215 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1775 GRAND CONCOURSE FL 6 | ||||||||
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| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104538202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185901800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2018 | ||||||||
| LastUpdateDate: | 04/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | ARROYO | ||||||||
| AuthorizedOfficialFirstName: | MARIVEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DENTAL RESIDENCY COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7189018410 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.