=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184776908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEPENTHE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 BROOK AVE UNIT 29
-----------------------------------------------------
City | DEER PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11729-6829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-243-3056
-----------------------------------------------------
Fax | 631-243-3132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 435 BROOK AVE UNIT 29
-----------------------------------------------------
City | DEER PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11729-6829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-243-3056
-----------------------------------------------------
Fax | 631-243-3132
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL BILLER
-----------------------------------------------------
Name | MS. ROSANNE M MIRANDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-243-3056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 01467110
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------