Healthcare Provider Details

I. General information

NPI: 1679072516
Provider Name (Legal Business Name): MINNIE MAE SOCIAL ADULT DAY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S FULTON AVE
MOUNT VERNON NY
10553
US

IV. Provider business mailing address

296 WARREN ST
BROOKLYN NY
11201-6590
US

V. Phone/Fax

Practice location:
  • Phone: 914-292-1064
  • Fax: 914-863-2070
Mailing address:
  • Phone: 347-556-5188
  • Fax:

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: MS. LISA MILLS
Title or Position: DIRECTOR
Credential: LMSW, CASAC
Phone: 347-556-5188