Healthcare Provider Details

I. General information

NPI: 1134253263
Provider Name (Legal Business Name): TRANSITIONAL SERVICE OF NY FOR LI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 SUFFOLK AVE
BRENTWOOD NY
11717-4404
US

IV. Provider business mailing address

840 SUFFOLK AVE
BRENTWOOD NY
11717-4404
US

V. Phone/Fax

Practice location:
  • Phone: 631-231-3619
  • Fax: 631-231-4754
Mailing address:
  • Phone: 631-231-3619
  • Fax: 631-231-4754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number01304530
License Number StateNY

VIII. Authorized Official

Name: MR. BRUNO LA SPINA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 631-231-3619