Healthcare Provider Details

I. General information

NPI: 1285750737
Provider Name (Legal Business Name): COUNTY OF SUFFOLK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 SUNRISE HWY STE 124 POB 9006
GREAT RIVER NY
11739-1001
US

IV. Provider business mailing address

3500 SUNRISE HWY STE 124 POB 9006
GREAT RIVER NY
11739-1001
US

V. Phone/Fax

Practice location:
  • Phone: 631-854-0182
  • Fax: 631-854-0199
Mailing address:
  • Phone: 631-854-0182
  • Fax: 631-854-0199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number5155200R
License Number StateNY

VIII. Authorized Official

Name: DARLENE A WILSON
Title or Position: ADMINISTRATOR II
Credential:
Phone: 631-854-0193