=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922931344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEISURE VILLAGE MEDICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2026
-----------------------------------------------------
Last Update Date | 06/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 681 WHISKEY RD UNIT 2
-----------------------------------------------------
City | RIDGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11961-8351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-675-0488
-----------------------------------------------------
Fax | 934-899-0421
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 681 WHISKEY RD UNIT 2
-----------------------------------------------------
City | RIDGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11961-8351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-675-0488
-----------------------------------------------------
Fax | 934-899-0421
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NATHANAEL DESIRE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 631-806-7341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------