=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558798454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RYAN NENA CHC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2013
-----------------------------------------------------
Last Update Date | 10/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 279 E 3RD ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10009-7813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-477-5804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 279 E 3RD ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10009-7813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-477-5804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KATHY GRUBER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-477-8866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 7960682
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------