Basic Information
| Provider Information | |||||||||
| NPI: | 1699811166 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAUGHTERS OF JACOB ADULT DAY CARE PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 TELLER AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104564145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182931500 | ||||||||
| FaxNumber: | 7189927074 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 TELLER AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104564145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182931500 | ||||||||
| FaxNumber: | 7189927074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PREIRA | ||||||||
| AuthorizedOfficialFirstName: | GILBERT | ||||||||
| AuthorizedOfficialMiddleName: | MANUEL | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7182931500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | 7000342N | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | 01164130 | 05 | NY | MEDICAID |