Basic Information
| Provider Information | |||||||||
| NPI: | 1639255797 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRONXCARE SPECIAL CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1276 FULTON AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104563402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089018600 | ||||||||
| FaxNumber: | 7182931475 | ||||||||
| Practice Location | |||||||||
| Address1: | 1265 FULTON AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189018600 | ||||||||
| FaxNumber: | 7182931475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | DEMARCO | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP-CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7189018600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 314000000X | 7000364N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 01350930 | 05 | NY | MEDICAID |