MEDICARE: JVJ EARLY INTERVENTION CORP

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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1760015671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JVJ EARLY INTERVENTION CORP

Provider Business Mailing Address
First Line	:	176 LITTLE NECK RD
Second Line	:
City	:	CENTERPORT
State	:	NY
Zip	:	11721-1144
Country	:	US
Telephone Number	:	516-404-1690
Fax Number	:

Provider Business Practice Location Address
First Line	:	176 LITTLE NECK RD
Second Line	:
City	:	CENTERPORT
State	:	NY
Zip	:	11721-1144
Country	:	US
Telephone Number	:	516-404-1690
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. ROSE WYKA
Credential	:	MSED
Telephone Number	:	516-404-1690

Provider Enumeration Date	:	02/19/2020
Last Update Date	:	02/19/2020

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