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General NPI Number Information
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NPI Number | 1457721482
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Entity Type | Organization
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Legal Business Name | GRACEFUL DOVE, LLC
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Dates
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Enumeration Date | 10/02/2015
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Last Update Date | 10/02/2015
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Provider Practice Location Address
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Address Line | 4521 ARTHUR KILL RD SUITE A
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City | STATEN ISLAND
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State | NY
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Zip | 10309-1315
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Country | US
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Telephone | 718-552-5179
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Fax | 718-554-4069
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Provider Business Mailing Address
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Address Line | 4521 ARTHUR KILL RD
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City | STATEN ISLAND
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State | NY
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Zip | 10309-1315
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Country | US
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Telephone | 718-552-5179
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Fax | 718-554-4069
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Authorized Official
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Title or Position | DIRECTOR OF OPERATION
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Name | VICTOR SEDAROS
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Credential |
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Telephone | 718-552-5179
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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