Healthcare Provider Details

I. General information

NPI: 1750570495
Provider Name (Legal Business Name): MISSION OF THE IMMACULATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6581 HYLAN BLVD
STATEN ISLAND NY
10309-3830
US

IV. Provider business mailing address

6581 HYLAN BLVD
STATEN ISLAND NY
10309-3830
US

V. Phone/Fax

Practice location:
  • Phone: 718-317-2803
  • Fax: 718-317-2830
Mailing address:
  • Phone: 718-317-2803
  • Fax: 718-317-2830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number7943430
License Number StateNY

VIII. Authorized Official

Name: MR. STEPHEN W RYNN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 718-317-2803