Healthcare Provider Details

I. General information

NPI: 1669925533
Provider Name (Legal Business Name): ROCKAWAY KIDNEY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 BEACH 20TH ST
FAR ROCKAWAY NY
11691-3645
US

IV. Provider business mailing address

529 BEACH 20TH ST
FAR ROCKAWAY NY
11691-3645
US

V. Phone/Fax

Practice location:
  • Phone: 516-770-5712
  • Fax: 718-228-8036
Mailing address:
  • Phone: 516-770-5712
  • Fax: 718-228-8036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OLUSEGUN OGUNFOWORA
Title or Position: MD
Credential: MD
Phone: 516-770-5712