MEDICARE: 55 SANDALWOOD ENTERPRISES INC

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	174400000X	Specialist	15000010884	NY

General Provider Information

NPI Number	:	1083691539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	55 SANDALWOOD ENTERPRISES INC

Provider Business Mailing Address
First Line	:	20 MEDFORD AVE
Second Line	:
City	:	PATCHOGUE
State	:	NY
Zip	:	11772-1220
Country	:	US
Telephone Number	:	631-447-7938
Fax Number	:	631-447-7939

Provider Business Practice Location Address
First Line	:	3400 BAINBRIDGE AVE
Second Line	:	GREENE MEDICAL ARTS PAVILION 3RD FLOOR
City	:	BRONX
State	:	NY
Zip	:	10467-2404
Country	:	US
Telephone Number	:	718-920-4333
Fax Number	:	631-447-7939

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MS. PHYLLIS ZENKER
Credential	:	AA
Telephone Number	:	631-447-7938

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	08/22/2020

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