Healthcare Provider Details

I. General information

NPI: 1982878757
Provider Name (Legal Business Name): SAMARITAN DAYTOP VILLAGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14401 JAMAICA AVE
JAMAICA NY
11435-3601
US

IV. Provider business mailing address

13802 QUEENS BLVD
BRIARWOOD NY
11435-2642
US

V. Phone/Fax

Practice location:
  • Phone: 718-206-1990
  • Fax: 718-206-0051
Mailing address:
  • Phone: 718-206-2000
  • Fax: 718-206-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number080311278
License Number StateNY

VIII. Authorized Official

Name: CHARLES MADRAY
Title or Position: VP OF HEALTH SERVICES & COMMUNITY B
Credential: MBA
Phone: 718-206-2000