MEDICARE: REBORN FOR NEW LIFE 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	261QH0100X	Health Service Clinic/Center
2	261Q00000X	Clinic/Center	150211831	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	150211831	OTHER	NY	OASAS

General Provider Information

NPI Number	:	1598181513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REBORN FOR NEW LIFE LLC

Provider Business Mailing Address
First Line	:	400 LIBERTY AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-3032
Country	:	US
Telephone Number	:	646-251-1400
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 LIBERTY AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-3032
Country	:	US
Telephone Number	:	646-251-1400
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. WILKINS WILLIAMS
Credential	:
Telephone Number	:	917-553-0982

Provider Enumeration Date	:	03/14/2014
Last Update Date	:	04/01/2014

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Directions to “REBORN FOR NEW LIFE LLC ” Practice Location

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