Healthcare Provider Details

I. General information

NPI: 1346424702
Provider Name (Legal Business Name): BRONX REGIONAL HIGH SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

979 ROGERS PL
BRONX NY
10459-3053
US

IV. Provider business mailing address

PO BOX 4156 CHURCH STREET STATION
NEW YORK NY
10261-4156
US

V. Phone/Fax

Practice location:
  • Phone: 718-696-4071
  • Fax:
Mailing address:
  • Phone: 718-920-4649
  • Fax: 718-515-5419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES BROCKET
Title or Position: ADMINISTRATOR
Credential:
Phone: 718-920-4167