MEDICARE: DEPT OF EDUCATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3140N1450X	Pediatric Skilled Nursing Facility	22-528487	NJ

General Provider Information

NPI Number	:	1073889754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEPT OF EDUCATION

Provider Business Mailing Address
First Line	:	139 KIMBALL TERRENCE
Second Line	:	HOUSE
City	:	YONKERS
State	:	NY
Zip	:	10704
Country	:	US
Telephone Number	:	718-842-2655
Fax Number	:	718-328-5506

Provider Business Practice Location Address
First Line	:	1535 STORY AVE
Second Line	:	SCHOOL
City	:	BRONX
State	:	NY
Zip	:	10473-4555
Country	:	US
Telephone Number	:	718-842-2655
Fax Number	:	718-328-5506

Authorized Official
Title or Position	:	NURSE
Name	:	CELY LUSARIA
Credential	:	RN
Telephone Number	:	718-842-2655

Provider Enumeration Date	:	03/28/2012
Last Update Date	:	03/28/2012

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Directions to “DEPT OF EDUCATION ” Practice Location

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