Basic Information
| Provider Information | |||||||||
| NPI: | 1811153760 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IRVINGTON HEALTHCARE PROVIDERS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 40TH ST | ||||||||
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| City: | IRVINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071111184 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 170 53RD ST | ||||||||
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| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112324316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185670400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2008 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | CHAVIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7185670400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | 89833704 | 05 | NJ | MEDICAID |