MEDICARE: ICL MEDICAID SERVICE COORDINATION (MSC)

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	251C00000X	Developmentally Disabled Services Day Training Agency

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	:	1376873265
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICL MEDICAID SERVICE COORDINATION (MSC)

Provider Business Mailing Address
First Line	:	6209 16TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-2702
Country	:	US
Telephone Number	:	718-234-0073
Fax Number	:

Provider Business Practice Location Address
First Line	:	6209 16TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-2702
Country	:	US
Telephone Number	:	718-234-0073
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	DEWEY HOWARD
Credential	:
Telephone Number	:	212-385-3030

Provider Enumeration Date	:	12/28/2009
Last Update Date	:	12/28/2009

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Directions to “ICL MEDICAID SERVICE COORDINATION (MSC) ” Practice Location

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