Healthcare Provider Details

I. General information

NPI: 1881366581
Provider Name (Legal Business Name): REBECCA A KINCADE IDHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MORICHES ISLAND ROAD
EAST MORICHES NY
11940
US

IV. Provider business mailing address

100 MORICHES ISLAND RD
EAST MORICHES NY
11940-1315
US

V. Phone/Fax

Practice location:
  • Phone: 631-395-4435
  • Fax:
Mailing address:
  • Phone: 631-395-4435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: