Healthcare Provider Details

I. General information

NPI: 1164475133
Provider Name (Legal Business Name): FAR ROCKAWAY VA CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1288 CENTRAL AVE 1288 CENTRAL AVE.
FAR ROCKAWAY NY
11691-3909
US

IV. Provider business mailing address

1288 CENTRAL AVE
FAR ROCKAWAY NY
11691-3909
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-7150
  • Fax: 718-634-2155
Mailing address:
  • Phone: 718-945-7150
  • Fax: 718-634-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARBARA MAYERICK
Title or Position: DIRECTOR, BUSINESS DEVELOPMENT
Credential:
Phone: 202-254-0339