Healthcare Provider Details

I. General information

NPI: 1700126604
Provider Name (Legal Business Name): TRI-STATE ADULT DAY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114-12 125 STREET
SOUTH OZONE PARK NY
11420
US

IV. Provider business mailing address

114-12 125 STREET
SOUTH OZONE PARK NY
11420
US

V. Phone/Fax

Practice location:
  • Phone: 917-651-4003
  • Fax:
Mailing address:
  • Phone: 917-651-4003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICTOR PRASAD
Title or Position: OWNER
Credential:
Phone: 917-651-4003