Basic Information
Provider Information | |||||||||
NPI: | 1982878757 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAMARITAN DAYTOP VILLAGE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAMARITAN VILLAGE, INC. | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13802 QUEENS BLVD | ||||||||
Address2: |   | ||||||||
City: | BRIARWOOD | ||||||||
State: | NY | ||||||||
PostalCode: | 114352642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7182062000 | ||||||||
FaxNumber: | 7182064055 | ||||||||
Practice Location | |||||||||
Address1: | 14401 JAMAICA AVE | ||||||||
Address2: |   | ||||||||
City: | JAMAICA | ||||||||
State: | NY | ||||||||
PostalCode: | 114353601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7182061990 | ||||||||
FaxNumber: | 7182060051 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2008 | ||||||||
LastUpdateDate: | 04/29/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MADRAY | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF HEALTH SERVICES & COMMUNITY B | ||||||||
AuthorizedOfficialTelephone: | 7182062000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 080311278 | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | 080311278 | 01 | NY | OASAS LIC# | OTHER | 16890 | 01 | NY | OASAS PROVIDER # | OTHER | 000245309 | 05 | NY |   | MEDICAID | PRU #6595 | 01 | NY | OASAS PROG,REPORT # | OTHER |