=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043285927
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARDEN CITY MEDICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 FRONT ST 303
-----------------------------------------------------
City | HEMPSTEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11550-3601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-565-4789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 FRONT ST
-----------------------------------------------------
City | HEMPSTEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11550-3601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-565-4789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | LUZ DAVILA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-565-4789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 159622
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------