Healthcare Provider Details

I. General information

NPI: 1821376005
Provider Name (Legal Business Name): OMNICARE MULTI SPECIALTY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763-765 NOSTRAND AVENUE
BROOKLYN NY
11216
US

IV. Provider business mailing address

763-765 NOSTRAND AVE
BROOKLYN NY
11216-4203
US

V. Phone/Fax

Practice location:
  • Phone: 718-774-0171
  • Fax: 718-773-7470
Mailing address:
  • Phone: 718-774-0171
  • Fax: 718-773-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number177953
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number177953
License Number StateNY

VIII. Authorized Official

Name: MRS. REGINE SERRANO
Title or Position: CREDENTIALING MANAGER
Credential: PARALEGAL
Phone: 718-774-0171