Healthcare Provider Details

I. General information

NPI: 1972926814
Provider Name (Legal Business Name): WYCKOFF PEDIATRIC CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date: 06/29/2015
Reactivation Date: 06/29/2015

III. Provider practice location address

1411 MYRTLE AVE 1411 MYRTLE AVENUE
BROOKLYN NY
11237-4512
US

IV. Provider business mailing address

1411 MYRTLE AVE WYCKOFF PEDIATRIC CARE CENTER
BROOKLYN NY
11237-4512
US

V. Phone/Fax

Practice location:
  • Phone: 718-907-4301
  • Fax: 718-919-1309
Mailing address:
  • Phone: 718-907-4301
  • Fax: 718-919-1309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: VALI GACHE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 718-240-1795