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General NPI Number Information
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NPI Number | 1538042650
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Entity Type | Organization
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Legal Business Name | MBD CARE LLC
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Dates
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Enumeration Date | 07/28/2025
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Last Update Date | 07/28/2025
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Provider Practice Location Address
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Address Line | 3350 VICTORY BLVD
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City | STATEN ISLAND
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State | NY
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Zip | 10314-6792
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Country | US
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Telephone | 917-721-4494
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Fax |
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Provider Business Mailing Address
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Address Line | 36 BORMAN AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10314-4957
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Country | US
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Telephone | 917-721-4494
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGING MEMBER
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Name | TATIANA KIDANOV
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Credential | MS,RD,CDN,CDCES
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Telephone | 917-721-4494
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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