Healthcare Provider Details

I. General information

NPI: 1033593488
Provider Name (Legal Business Name): BEACON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14838 HUXLEY ST
ROSEDALE NY
11422-2720
US

IV. Provider business mailing address

14838 HUXLEY ST
ROSEDALE NY
11422-2720
US

V. Phone/Fax

Practice location:
  • Phone: 917-750-4929
  • Fax:
Mailing address:
  • Phone: 917-750-4929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number004244-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number004244-1
License Number StateNY

VIII. Authorized Official

Name: LORRAINE L BEATON-FUNG
Title or Position: NUTRITIONIST
Credential: BS/CDN/CLC
Phone: 917-750-4929