=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760441489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOYS CLUB OF NEW YORK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 287 E 10TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10009-4816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-533-2554
-----------------------------------------------------
Fax | 212-353-0016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 287 E 10TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10009-4816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-533-2554
-----------------------------------------------------
Fax | 212-353-0016
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. BRAD ZERVAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-533-2554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------