Healthcare Provider Details

I. General information

NPI: 1548347719
Provider Name (Legal Business Name): SAMARITAN VILLAGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WEST 125TH STREET 11TH FLOOR
NEW YORK NY
10027
US

IV. Provider business mailing address

138-02 QUEENS BLVD
BRIARWOOD NY
11435
US

V. Phone/Fax

Practice location:
  • Phone: 212-865-9182
  • Fax: 212-662-9193
Mailing address:
  • Phone: 718-206-2000
  • Fax: 718-206-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number080911571
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUGLAS APPLE
Title or Position: EXECUTIVE VP/COO
Credential:
Phone: 718-206-2000