Basic Information
| Provider Information | |||||||||
| NPI: | 1619539996 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUEENS BOULEVARD EXTENDED CARE FACILITY DIALYSIS CENTER LLC | ||||||||
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| OtherOrganizationName: | QUEENS BOULEVARD EXTENDED CARE DIALYSIS CENTER LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6111 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182050287 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6111 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182050287 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2019 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | CLEMENZA | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7182050287 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.