MEDICARE: CATHOLIC CHARITIES OF THE DIOCESE OF ROCKVILLE CENTRE

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	6814102A	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6814100A	OTHER	NY	OMH OPERATING CERTIFICATE

General Provider Information

NPI Number	:	1437170537
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CATHOLIC CHARITIES OF THE DIOCESE OF ROCKVILLE CENTRE

Provider Business Mailing Address
First Line	:	90 CHERRY LN
Second Line	:
City	:	HICKSVILLE
State	:	NY
Zip	:	11801-6232
Country	:	US
Telephone Number	:	516-733-7040
Fax Number	:

Provider Business Practice Location Address
First Line	:	1727 N OCEAN AVE
Second Line	:
City	:	MEDFORD
State	:	NY
Zip	:	11763-2649
Country	:	US
Telephone Number	:	631-654-1919
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MR. RICHARD BALCOM
Credential	:
Telephone Number	:	516-733-7032

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	03/31/2017

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