Healthcare Provider Details

I. General information

NPI: 1972560167
Provider Name (Legal Business Name): SANCTUARY EAST LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2006
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 WILLIAM AVE
EAST ISLIP NY
11730-2330
US

IV. Provider business mailing address

2 WILLIAM AVE
EAST ISLIP NY
11730-2330
US

V. Phone/Fax

Practice location:
  • Phone: 631-224-7700
  • Fax: 631-224-7600
Mailing address:
  • Phone: 631-224-7700
  • Fax: 631-224-7600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number070210970
License Number StateNY

VIII. Authorized Official

Name: LORENZO RODRIGUEZ
Title or Position: DIRECTOR
Credential: A.A., CASAC
Phone: 631-224-7700