=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205048105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URBAN RESOURCE INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 12/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15519 LINDEN BLVD
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11434-1017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-588-0030
-----------------------------------------------------
Fax | 646-588-0033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 BROAD ST SUITE 505
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10004-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-588-0030
-----------------------------------------------------
Fax | 646-588-0033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VICE PRESIDENT, FINANCE/CFO
-----------------------------------------------------
Name | DONOVAN MURRAY
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 646-588-0040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 7712440
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------