Basic Information
| Provider Information | |||||||||
| NPI: | 1508326851 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTERS AGENCY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CENTERS LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4770 WHITE PLAINS RD | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104701104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189319700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1412 BAY RIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112196231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189319700 | ||||||||
| FaxNumber: | 7182590088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2019 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROZENBERG | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7189319700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 06049678 | 05 | NY | MEDICAID |