Healthcare Provider Details

I. General information

NPI: 1861732893
Provider Name (Legal Business Name): SHADOW HOUSING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2013
Last Update Date: 02/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3560 OLINVILLE AVE APT 1F 2118 WILLLIAMBRIDGE ROAD
BRONX NY
10467-5533
US

IV. Provider business mailing address

3560 OLINVILLE AVE APT 1F 2118 WILLLIAMBRIDGE ROAD
BRONX NY
10467-5533
US

V. Phone/Fax

Practice location:
  • Phone: 718-618-7337
  • Fax: 646-401-7420
Mailing address:
  • Phone: 718-618-7337
  • Fax: 646-401-7420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number3333470
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number33335470
License Number StateNY

VIII. Authorized Official

Name: MR. JOE WRIGHT
Title or Position: CEO
Credential:
Phone: 718-618-7337