Basic Information
| Provider Information | |||||||||
| NPI: | 1689111734 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAMARITAN DAYTOP VILLAGE | ||||||||
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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: | 751 BRIGGS HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | ELLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182062000 | ||||||||
| FaxNumber: | 7182064055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2017 | ||||||||
| LastUpdateDate: | 01/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | HOLLYWOOD | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, RESIDENTIAL TREATMENT | ||||||||
| AuthorizedOfficialTelephone: | 7182062000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 161111750 | NY | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 00245309 | 01 | NY | MEDICAID | OTHER |