MEDICARE: GLADYS HENRY

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	3140N1450X	Pediatric Skilled Nursing Facility	316201-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	316201-1	OTHER	NY	OFFICE OF THE PROFESSIONS

General Provider Information

NPI Number	:	1275921421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLADYS HENRY

Provider Business Mailing Address
First Line	:	870 E 223RD ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-4402
Country	:	US
Telephone Number	:	914-888-4823
Fax Number	:

Provider Business Practice Location Address
First Line	:	870 E 223RD ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-4402
Country	:	US
Telephone Number	:	914-888-4823
Fax Number	:

Authorized Official
Title or Position	:	LPN
Name	:	GLADYS HENRY
Credential	:
Telephone Number	:	914-888-4823

Provider Enumeration Date	:	12/22/2014
Last Update Date	:	12/22/2014

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