MEDICARE: PAUL J COOPER CENTER FOR HUMAN SERVICES, INC - IRA SUPP

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

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	:	1609047455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL J COOPER CENTER FOR HUMAN SERVICES, INC - IRA SUPP

Provider Business Mailing Address
First Line	:	519 ROCKAWAY AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11212-5638
Country	:	US
Telephone Number	:	718-498-5555
Fax Number	:

Provider Business Practice Location Address
First Line	:	519 ROCKAWAY AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11212-5638
Country	:	US
Telephone Number	:	718-498-5555
Fax Number	:

Authorized Official
Title or Position	:	BILLING OFFICER
Name	:	CINDY AMBROSE
Credential	:
Telephone Number	:	718-498-5555

Provider Enumeration Date	:	03/20/2008
Last Update Date	:	03/20/2008

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