Healthcare Provider Details

I. General information

NPI: 1003318312
Provider Name (Legal Business Name): CRYSTAL ADULT SOCIAL DAY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138-31 QUEENS BLVD
JAMAICA NY
11435
US

IV. Provider business mailing address

13831 QUEENS BLVD
JAMAICA NY
11435-2641
US

V. Phone/Fax

Practice location:
  • Phone: 718-642-0011
  • Fax: 718-558-9290
Mailing address:
  • Phone: 718-642-0011
  • Fax: 718-558-9290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SVETLANA RAKHMAN
Title or Position: GENERAL MANAGER
Credential:
Phone: 917-674-5788