=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164475133
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAR ROCKAWAY VA CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 08/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1288 CENTRAL AVE 1288 CENTRAL AVE.
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-945-7150
-----------------------------------------------------
Fax | 718-634-2155
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1288 CENTRAL AVE
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-945-7150
-----------------------------------------------------
Fax | 718-634-2155
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, BUSINESS DEVELOPMENT
-----------------------------------------------------
Name | BARBARA MAYERICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-254-0339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QV0200X
-----------------------------------------------------
Taxonomy Name | VA Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------