Healthcare Provider Details

I. General information

NPI: 1235112574
Provider Name (Legal Business Name): INTREPID OF NEW YORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 MERRICK RD FL2
SEAFORD NY
11783-2823
US

IV. Provider business mailing address

4055 VALLEY VIEW LN 5TH FLOOR
DALLAS TX
75244-5074
US

V. Phone/Fax

Practice location:
  • Phone: 516-781-7777
  • Fax: 516-781-3252
Mailing address:
  • Phone: 214-445-3750
  • Fax: 214-445-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1067L001
License Number StateNY

VIII. Authorized Official

Name: MR. PAUL D FOSTER
Title or Position: CEO
Credential:
Phone: 214-445-3750