MEDICARE: NY CHILD GROW LLC

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1508368515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NY CHILD GROW LLC

Provider Business Mailing Address
First Line	:	PO BOX 672281
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-0806
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3603 BAINBRIDGE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-1168
Country	:	US
Telephone Number	:	347-349-5994
Fax Number	:

Authorized Official
Title or Position	:	ORGANIZER
Name	:	WANDA GARCIA
Credential	:
Telephone Number	:	347-349-5994

Provider Enumeration Date	:	03/06/2018
Last Update Date	:	03/06/2018

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