=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538423892
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YAN RAYKIS MS ED/SPECIAL ED
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2012
-----------------------------------------------------
Last Update Date | 03/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2439 E 3RD ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11223-6043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-703-4643
-----------------------------------------------------
Fax | 347-492-4888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O.BOX 957 ( 103 LIVINGSTON LANE )
-----------------------------------------------------
City | GOULDSBORO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-703-4643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------