Basic Information
| Provider Information | |||||||||
| NPI: | 1194085662 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKAWAY HD LLC | ||||||||
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| OtherOrganizationName: | ROCKAWAY DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 529 BEACH 20TH STREET | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116913645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183274503 | ||||||||
| FaxNumber: | 7183270043 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 BEACH 20TH ST | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116913645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183277307 | ||||||||
| FaxNumber: | 7183273297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2012 | ||||||||
| LastUpdateDate: | 07/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | OGUNFOWORA | ||||||||
| AuthorizedOfficialFirstName: | OLUSEGUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7183274503 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 206115 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.