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General NPI Number Information
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NPI Number | 1083691539
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Entity Type | Organization
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Legal Business Name | 55 SANDALWOOD ENTERPRISES INC
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Dates
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Enumeration Date | 12/27/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3400 BAINBRIDGE AVE GREENE MEDICAL ARTS PAVILION 3RD FLOOR
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City | BRONX
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State | NY
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Zip | 10467-2404
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Country | US
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Telephone | 718-920-4333
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Fax | 631-447-7939
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Provider Business Mailing Address
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Address Line | 20 MEDFORD AVE
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City | PATCHOGUE
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State | NY
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Zip | 11772-1220
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Country | US
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Telephone | 631-447-7938
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Fax | 631-447-7939
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | MS. PHYLLIS ZENKER
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Credential | AA
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Telephone | 631-447-7938
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 15000010884
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License Number State | NY
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