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General NPI Number Information
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NPI Number | 1649455809
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Entity Type | Organization
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Legal Business Name | LIFELONG THERAPUTICS INC
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Dates
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Enumeration Date | 01/07/2008
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Last Update Date | 01/07/2008
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Provider Practice Location Address
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Address Line | 337 DEER PARK RD
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City | DIX HILLS
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State | NY
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Zip | 11746-5203
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Country | US
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Telephone | 631-385-2411
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Fax | 631-385-2411
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Provider Business Mailing Address
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Address Line | 143 CHARDONNAY DR
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City | EAST QUOGUE
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State | NY
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Zip | 11942-3829
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Country | US
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Telephone | 631-385-2411
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Fax | 631-385-2411
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Authorized Official
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Title or Position | OWNER
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Name | MR. JEFFREY CIOLINO
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Credential | OTR/L
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Telephone | 631-385-2411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number | 2595
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License Number State | NY
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