Healthcare Provider Details

I. General information

NPI: 1235897653
Provider Name (Legal Business Name): CORONA ING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3719 108TH ST
CORONA NY
11368-4176
US

IV. Provider business mailing address

3719 108TH ST
CORONA NY
11368-4176
US

V. Phone/Fax

Practice location:
  • Phone: 718-406-9032
  • Fax: 917-745-1561
Mailing address:
  • Phone: 718-406-9032
  • Fax: 917-745-1561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: ROZA BAGDASAROVA
Title or Position: OWNER
Credential:
Phone: 718-406-9032