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NPI Code Detail

MEDICARE: QUEENS REPLACEMENT LLC

MEDICARE: QUEENS REPLACEMENT LLC
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
1261QE0700XEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center7003264RNY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1548251218
Entity Type Code : Organization
Provider Name (Legal Business Name) : QUEENS REPLACEMENT LLC
Provider Business Mailing Address
First Line : 97 NEW DORP LN
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10306-2364
Country : US
Telephone Number : 718-448-5641
Fax Number : 718-876-5969
Provider Business Practice Location Address
First Line : 12046 QUEENS BLVD
Second Line :
City : KEW GARDENS
State : NY
Zip : 11415-1204
Country : US
Telephone Number : 718-793-3341
Fax Number : 718-268-1666
Authorized Official
Title or Position : ADMINISTRATOR
Name : MR. DOMINIC LICCIARDI
Credential :
Telephone Number : 718-987-5942
Provider Enumeration Date : 11/02/2005
Last Update Date : 09/30/2013

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