Healthcare Provider Details

I. General information

NPI: 1396806881
Provider Name (Legal Business Name): SAINT JOHNS HOME FOR BOYS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BEACH 110TH STREET
ROCKAWAY PARK NY
11694
US

IV. Provider business mailing address

150 BEACH 110TH STREET
ROCKAWAY PARK NY
11694
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-2800
  • Fax: 718-945-4662
Mailing address:
  • Phone: 718-945-2800
  • Fax: 718-945-4662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DARVING C IRIZARRY
Title or Position: DIRECTOR OF SPECIAL SERVICES & OPER
Credential: LMSW
Phone: 718-945-2800