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General NPI Number Information
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NPI Number | 1063010767
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Entity Type | Organization
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Legal Business Name | 6677 BROADWAY LLC
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Dates
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Enumeration Date | 10/14/2020
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Last Update Date | 10/14/2020
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Provider Practice Location Address
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Address Line | 140 BEACH 119TH ST
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City | ROCKAWAY PARK
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State | NY
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Zip | 11694-1953
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Country | US
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Telephone | 718-938-7183
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Fax |
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Provider Business Mailing Address
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Address Line | 4718 18TH AVE STE 26
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City | BROOKLYN
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State | NY
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Zip | 11204-1260
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Country | US
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Telephone | 718-938-7183
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ANGELA BORUKHOVA
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Credential |
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Telephone | 718-938-7183
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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