=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376935957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAYSTAR FORMEDICALLY FRAGILE CHILDREN, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2015
-----------------------------------------------------
Last Update Date | 02/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 LAC DE VILLE BLVD
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14618-5665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-385-6287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 LAC DE VILLE BLVD
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14618-5665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-385-6287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCE DIRECTOR
-----------------------------------------------------
Name | DENIQUE CONNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 585-385-6287
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385HR2065X
-----------------------------------------------------
Taxonomy Name | Child Physical Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------