=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972916344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UJIMA HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2014
-----------------------------------------------------
Last Update Date | 06/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1808 3RD AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-6103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-632-3920
-----------------------------------------------------
Fax | 646-632-3939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2006 MADISON AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10035-1217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-979-8800
-----------------------------------------------------
Fax | 212-979-8917
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND CEO
-----------------------------------------------------
Name | MR. MARK HURWITZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-979-8800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 150511550
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------