Healthcare Provider Details

I. General information

NPI: 1295930113
Provider Name (Legal Business Name): 360 KNICKER CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 KNICKERBOCKER AVE
BROOKLYN NY
11237-3751
US

IV. Provider business mailing address

360 KNICKERBOCKER AVE
BROOKLYN NY
11237-3751
US

V. Phone/Fax

Practice location:
  • Phone: 718-455-1301
  • Fax: 718-455-1375
Mailing address:
  • Phone: 718-455-1301
  • Fax: 718-455-1375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: MS. IVELISSE CARIDAD CHARLOTTEN
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 212-426-7151