Healthcare Provider Details

I. General information

NPI: 1104379593
Provider Name (Legal Business Name): WYCKOFF HEIGHTS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 CHRISTOPHER AVE
BROOKLYN NY
11212-7029
US

IV. Provider business mailing address

545 CHRISTOPHER AVE
BROOKLYN NY
11212-7029
US

V. Phone/Fax

Practice location:
  • Phone: 347-466-6341
  • 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

VIII. Authorized Official

Name: DESIREE BULLOCK
Title or Position: CLINICAL SUPERVISOR
Credential:
Phone: 347-466-6341