MEDICARE: CAROLE MARLY SURIN

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	311ZA0620X	Adult Care Home Facility	313619-1	NY

General Provider Information

NPI Number	:	1346618212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLE MARLY SURIN

Provider Business Mailing Address
First Line	:	13 SHERMAN DR
Second Line	:
City	:	SPRING VALLEY
State	:	NY
Zip	:	10977-4332
Country	:	US
Telephone Number	:	845-517-2034
Fax Number	:

Provider Business Practice Location Address
First Line	:	13 SHERMAN DR
Second Line	:
City	:	SPRING VALLEY
State	:	NY
Zip	:	10977-4332
Country	:	US
Telephone Number	:	845-300-3886
Fax Number	:

Authorized Official
Title or Position	:	LPN
Name	:	MRS. CAROLE MARLY SURIN
Credential	:
Telephone Number	:	845-300-3886

Provider Enumeration Date	:	09/09/2015
Last Update Date	:	09/09/2015

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