Basic Information
| Provider Information | |||||||||
| NPI: | 1396822839 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAMARITAN DAYTOP VILLAGE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAMARITAN VILLAGE, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13802 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114352642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182062000 | ||||||||
| FaxNumber: | 7182064055 | ||||||||
| Practice Location | |||||||||
| Address1: | 13020 89TH RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND HILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114183301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184418913 | ||||||||
| FaxNumber: | 7188056041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 02/02/2017 | ||||||||
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| AuthorizedOfficialLastName: | MADRAY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF HEALTH & COMM | ||||||||
| AuthorizedOfficialTelephone: | 7187644249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 16890 | NY | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 03A0973 | 01 | NY | NYDS-DOH LICENSE # | OTHER | 16890 | 01 | NY | NYS-OASAS PROVIDER # | OTHER | 000245309 | 05 | NY | MEDICAID | PRU-393 | 01 | NY | NYS-OASAS PROG.REPORT# | OTHER | PSO 169587 | 01 | NY | DEA LICENSE | OTHER | 080510352 | 01 | NY | NYS-OASAS CD OPR.CERT. | OTHER |