Healthcare Provider Details

I. General information

NPI: 1083691539
Provider Name (Legal Business Name): 55 SANDALWOOD ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 BAINBRIDGE AVE GREENE MEDICAL ARTS PAVILION 3RD FLOOR
BRONX NY
10467-2404
US

IV. Provider business mailing address

20 MEDFORD AVE
PATCHOGUE NY
11772-1220
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4333
  • Fax: 631-447-7939
Mailing address:
  • Phone: 631-447-7938
  • Fax: 631-447-7939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number15000010884
License Number StateNY

VIII. Authorized Official

Name: MS. PHYLLIS ZENKER
Title or Position: GENERAL MANAGER
Credential: AA
Phone: 631-447-7938