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General NPI Number Information
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NPI Number | 1093981235
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Entity Type | Organization
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Legal Business Name | THE LAKE GROVE SCHOOL
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Dates
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Enumeration Date | 05/07/2008
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Last Update Date | 05/07/2008
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Provider Practice Location Address
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Address Line | 3390 ROUTE 112
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City | MEDFORD
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State | NY
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Zip | 11763-1421
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Country | US
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Telephone | 631-696-1400
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Fax | 631-716-2135
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Provider Business Mailing Address
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Address Line | PO BOX 786
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City | MEDFORD
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State | NY
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Zip | 11763-0786
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Country | US
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Telephone | 631-969-1400
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Fax | 631-716-2135
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. FELIX WIENCLAW
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Credential |
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Telephone | 631-696-1400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State |
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