Healthcare Provider Details

I. General information

NPI: 1457444234
Provider Name (Legal Business Name): GODDARD RIVERSIDE COMMUNITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 COLUMBUS AVE
NEW YORK NY
10025-3140
US

IV. Provider business mailing address

593 COLUMBUS AVE
NEW YORK NY
10024-1904
US

V. Phone/Fax

Practice location:
  • Phone: 212-531-2727
  • Fax: 212-531-3636
Mailing address:
  • Phone: 212-873-6600
  • Fax: 212-595-6498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number7296471A
License Number StateNY

VIII. Authorized Official

Name: MR. LAURENCE KILLIAN
Title or Position: CHIEF FISCAL OFFICER
Credential:
Phone: 212-873-6600