Healthcare Provider Details

I. General information

NPI: 1750656021
Provider Name (Legal Business Name): D0E
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 JACOBUS ST
ELMHURST NY
11373-3702
US

IV. Provider business mailing address

5040 JACOBUS ST
ELMHURST NY
11373-3702
US

V. Phone/Fax

Practice location:
  • Phone: 718-429-7006
  • Fax: 718-429-6864
Mailing address:
  • Phone: 718-429-7006
  • Fax: 718-429-6864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number443418-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number443418-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0440065
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: MRS. MARIA ANDRES DAULO
Title or Position: STAFF NURSE
Credential: RN
Phone: 718-429-7006