Basic Information
| Provider Information | |||||||||
| NPI: | 1689864027 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUERTO RICAN FAMILY LACONIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 LACONIA AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104691402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124147822 | ||||||||
| FaxNumber: | 2126915635 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 W 15TH ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100116701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124147822 | ||||||||
| FaxNumber: | 2126915635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | CINA | ||||||||
| AuthorizedOfficialFirstName: | KARL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2122296921 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 06270440 | NY | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 00357135 | 05 | NY | MEDICAID |