Healthcare Provider Details

I. General information

NPI: 1942638309
Provider Name (Legal Business Name): MRS. BELLA MAKSUMOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10250 62ND RD APT 5S
FOREST HILLS NY
11375-1015
US

IV. Provider business mailing address

10250 62ND RD
FOREST HILLS NY
11375-1056
US

V. Phone/Fax

Practice location:
  • Phone: 718-592-8447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number610975
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number610975
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: