Healthcare Provider Details

I. General information

NPI: 1073803268
Provider Name (Legal Business Name): MILITARY COMMUNITY RESOURCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2011
Last Update Date: 04/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 OAK ST SUITE #1
PATCHOGUE NY
11772-2883
US

IV. Provider business mailing address

38 OAK ST SUITE #1
PATCHOGUE NY
11772-2883
US

V. Phone/Fax

Practice location:
  • Phone: 631-569-5811
  • Fax:
Mailing address:
  • Phone: 631-569-5811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: SHARON GINGOLA
Title or Position: EXECUTIVE DIRECTOR
Credential: M.A
Phone: 631-831-2271