=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700126604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-STATE ADULT DAY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2013
-----------------------------------------------------
Last Update Date | 03/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114-12 125 STREET
-----------------------------------------------------
City | SOUTH OZONE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-651-4003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114-12 125 STREET
-----------------------------------------------------
City | SOUTH OZONE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-651-4003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VICTOR PRASAD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-651-4003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------