=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164540522
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAKO RESIDENCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 380 EDS RD
-----------------------------------------------------
City | SOUTHOLD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11971-3716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-665-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 380 EDS RD
-----------------------------------------------------
City | SOUTHOLD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11971-3716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-665-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | EDWIN M KENNEDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-733-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 6186446
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------