Healthcare Provider Details

I. General information

NPI: 1003357815
Provider Name (Legal Business Name): KEW GARDENS SEP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15916 UNION TPKE SUITE 308
FRESH MEADOWS NY
11366-1954
US

IV. Provider business mailing address

159-16 UNION TPKE SUITE 308
FRESH MEADOWS NY
11375
US

V. Phone/Fax

Practice location:
  • Phone: 718-263-5437
  • Fax: 718-263-5444
Mailing address:
  • Phone: 718-263-5437
  • Fax: 718-263-5444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. LEONID YAKUBOV
Title or Position: EXECTIVE DIRECTOR
Credential: O.T.
Phone: 718-263-5437