Basic Information
| Provider Information | |||||||||
| NPI: | 1699891911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVENUE K (ICL) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 BROAD STREET | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100042400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123853030 | ||||||||
| FaxNumber: | 9178314451 | ||||||||
| Practice Location | |||||||||
| Address1: | 9001 AVENUE K | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112364215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183416091 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 06/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | HOWARD | ||||||||
| AuthorizedOfficialFirstName: | DEWEY | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2123853030 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | Y | Agencies | Day Training, Developmentally Disabled Services |
ID Information
| ID | Type | State | Issuer | Description | 01410099 | 05 | NY | MEDICAID |