MEDICARE: TENDERCARE EARLY INTERVENTION SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1073875837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TENDERCARE EARLY INTERVENTION SERVICES

Provider Business Mailing Address
First Line	:	36 SUNSET AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-5039
Country	:	US
Telephone Number	:	718-761-7581
Fax Number	:

Provider Business Practice Location Address
First Line	:	36 SUNSET AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-5039
Country	:	US
Telephone Number	:	718-761-7581
Fax Number	:

Authorized Official
Title or Position	:	PROPRIETOR
Name	:	OLUBUKOLA AFOLABI
Credential	:	MSED
Telephone Number	:	718-761-7581

Provider Enumeration Date	:	06/07/2012
Last Update Date	:	06/07/2012

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