Healthcare Provider Details

I. General information

NPI: 1952276065
Provider Name (Legal Business Name): FIESTA ADULT DAYCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2025
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 VICTORY BLVD FL 2
STATEN ISLAND NY
10314-6624
US

IV. Provider business mailing address

2200 VICTORY BLVD FL 2
STATEN ISLAND NY
10314-6624
US

V. Phone/Fax

Practice location:
  • Phone: 718-814-0555
  • Fax: 718-228-8999
Mailing address:
  • Phone: 718-814-0555
  • Fax: 718-228-8999

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: TATYANA F ELBERG
Title or Position: ADMINISTRATOR
Credential:
Phone: 718-996-0456