Healthcare Provider Details

I. General information

NPI: 1811434012
Provider Name (Legal Business Name): SAMARITAN DAYTOP VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13802 QUEENS BLVD
BRIARWOOD NY
11435-2642
US

IV. Provider business mailing address

13802 QUEENS BLVD
BRIARWOOD NY
11435-2642
US

V. Phone/Fax

Practice location:
  • Phone: 718-206-2000
  • Fax: 718-206-4055
Mailing address:
  • Phone: 718-206-2000
  • Fax: 718-206-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberC170110042
License Number StateNY

VIII. Authorized Official

Name: JAMES HOLLYWOOD
Title or Position: VP, RESIDENTIAL TREATMENT
Credential: LCSW
Phone: 718-206-2000