Basic Information
Provider Information | |||||||||
NPI: | 1538606686 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAMARITAN DAYTOP VILLAGE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13802 QUEENS BLVD | ||||||||
Address2: |   | ||||||||
City: | BRIARWOOD | ||||||||
State: | NY | ||||||||
PostalCode: | 114352642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7182062000 | ||||||||
FaxNumber: | 7182064055 | ||||||||
Practice Location | |||||||||
Address1: | 68 WEST 106TH ST | ||||||||
Address2: |   | ||||||||
City: | NY | ||||||||
State: | NY | ||||||||
PostalCode: | 10025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7182062000 | ||||||||
FaxNumber: | 7182064055 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2017 | ||||||||
LastUpdateDate: | 01/27/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOLLYWOOD | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP, RESIDENTIAL TREATMENT | ||||||||
AuthorizedOfficialTelephone: | 7182062000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 161211827 | NY | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
ID Information
ID | Type | State | Issuer | Description | 00245309 | 01 | NY | MEDICAID | OTHER |