Healthcare Provider Details

I. General information

NPI: 1770962391
Provider Name (Legal Business Name): WYCKOFF PEDIATRIC CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 STOCKHOLM STREET WYCKOFF HEIGHTS MEDICAL CENTER - FACULTY PRACTICE
BROOKLYN NY
11237
US

IV. Provider business mailing address

1411 MYRTLE AVENUE WYCKOFF PEDIATRIC CARE CENTER
BROOKLYN NY
11237
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-7272
  • Fax:
Mailing address:
  • Phone: 718-907-4301
  • Fax: 718-919-1309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. FRANK VUTRANO
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 718-963-6702