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General NPI Number Information
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NPI Number | 1033593488
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Entity Type | Organization
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Legal Business Name | BEACON
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Dates
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Enumeration Date | 07/15/2015
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Last Update Date | 07/15/2015
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Provider Practice Location Address
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Address Line | 14838 HUXLEY ST
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City | ROSEDALE
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State | NY
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Zip | 11422-2720
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Country | US
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Telephone | 917-750-4929
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Fax |
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Provider Business Mailing Address
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Address Line | 14838 HUXLEY ST
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City | ROSEDALE
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State | NY
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Zip | 11422-2720
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Country | US
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Telephone | 917-750-4929
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Fax |
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Authorized Official
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Title or Position | NUTRITIONIST
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Name | LORRAINE L BEATON-FUNG
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Credential | BS/CDN/CLC
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Telephone | 917-750-4929
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 004244-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | 004244-1
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License Number State | NY
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