Healthcare Provider Details

I. General information

NPI: 1528435872
Provider Name (Legal Business Name): HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E 181ST ST 6N
BRONX NY
10457-2305
US

IV. Provider business mailing address

333 E 181ST ST 6N
BRONX NY
10457-2305
US

V. Phone/Fax

Practice location:
  • Phone: 718-295-4833
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: KESHIA GRAHAM
Title or Position: FAMILY NURSE PRACTITIONER
Credential:
Phone: 718-295-4833