MEDICARE: INTREPID OF NEW YORK INC

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	251E00000X	Home Health Agency	1067L002	NY

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	:	1629050208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTREPID OF NEW YORK INC

Provider Business Mailing Address
First Line	:	4055 VALLEY VIEW LN
Second Line	:	5TH FLOOR
City	:	DALLAS
State	:	TX
Zip	:	75244-5074
Country	:	US
Telephone Number	:	214-445-3750
Fax Number	:	214-445-3902

Provider Business Practice Location Address
First Line	:	212-47 JAMAICA AVE
Second Line	:	2ND FLOOR, SUITE 209
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11428-1632
Country	:	US
Telephone Number	:	718-776-7760
Fax Number	:	718-776-7884

Authorized Official
Title or Position	:	CEO
Name	:	MR. PAUL D FOSTER
Credential	:
Telephone Number	:	214-445-3750

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	04/20/2016

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