Healthcare Provider Details

I. General information

NPI: 1073706032
Provider Name (Legal Business Name): RISEWELL COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 08/28/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 WAVERLY AVE
PATCHOGUE NY
11772-1586
US

IV. Provider business mailing address

1 FARMINGDALE ROUTE 109
WEST BABYLON NY
11704-6545
US

V. Phone/Fax

Practice location:
  • Phone: 631-447-6460
  • Fax: 631-289-7098
Mailing address:
  • Phone: 631-669-5355
  • Fax: 631-669-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number03007701
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier03007701
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: STEPHEN MCCARTHY
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CFO
Phone: 631-669-5355