Healthcare Provider Details

I. General information

NPI: 1457725905
Provider Name (Legal Business Name): AAVJN&AIJA CORNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2015
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13010 144TH ST
JAMAICA NY
11436-2214
US

IV. Provider business mailing address

13010 144TH ST
JAMAICA NY
11436-2214
US

V. Phone/Fax

Practice location:
  • Phone: 718-781-5417
  • Fax: 718-322-7480
Mailing address:
  • Phone: 718-781-5417
  • Fax: 718-322-7480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. DEBRA ANN BACCHUS
Title or Position: CEO/ OWNER
Credential:
Phone: 718-781-5417