Healthcare Provider Details

I. General information

NPI: 1730209362
Provider Name (Legal Business Name): FAGAN RESIDENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 DEPAUL ST
ELMONT NY
11003-1900
US

IV. Provider business mailing address

1504 DEPAUL ST
ELMONT NY
11003-1900
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-3434
  • Fax:
Mailing address:
  • Phone: 631-665-3434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number6186445
License Number StateNY

VIII. Authorized Official

Name: EDWIN M KENNEDY
Title or Position: CFO
Credential:
Phone: 516-733-7000