Healthcare Provider Details

I. General information

NPI: 1922931344
Provider Name (Legal Business Name): LEISURE VILLAGE MEDICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 WHISKEY RD UNIT 2
RIDGE NY
11961-8351
US

IV. Provider business mailing address

681 WHISKEY RD UNIT 2
RIDGE NY
11961-8351
US

V. Phone/Fax

Practice location:
  • Phone: 631-675-0488
  • Fax: 934-899-0421
Mailing address:
  • Phone: 631-675-0488
  • Fax: 934-899-0421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NATHANAEL DESIRE
Title or Position: OWNER
Credential: DO
Phone: 631-806-7341