MEDICARE: ISLAND REHABILITATIVE SERVICES CORP.

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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center		NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235130840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND REHABILITATIVE SERVICES CORP.

Provider Business Mailing Address
First Line	:	97 NEW DORP LN
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-2364
Country	:	US
Telephone Number	:	718-448-5641
Fax Number	:	718-876-5969

Provider Business Practice Location Address
First Line	:	470 SEAVIEW AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10305-3401
Country	:	US
Telephone Number	:	718-987-5942
Fax Number	:	718-667-9708

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. DOMINIC LICCIARDI
Credential	:
Telephone Number	:	718-987-5942

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	07/21/2022

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