=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255730602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUEENS LONG ISLAND CERTIFIED HOME HEALTH AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2014
-----------------------------------------------------
Last Update Date | 08/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3625 PARSONS BLVD
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-5938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-888-5294
-----------------------------------------------------
Fax | 718-461-9118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3625 PARSONS BLVD
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-5938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-888-5294
-----------------------------------------------------
Fax | 718-461-9118
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. JIA-LUO WANG
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 718-888-5294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 7003616
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------