MEDICARE: DM KIDS SERVICE

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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1700429602
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DM KIDS SERVICE

Provider Business Mailing Address
First Line	:	1180 BRIGHTON BEACH AVE APT 6B
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5838
Country	:	US
Telephone Number	:	646-404-4444
Fax Number	:

Provider Business Practice Location Address
First Line	:	1180 BRIGHTON BEACH AVE APT 6B
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5838
Country	:	US
Telephone Number	:	646-417-3816
Fax Number	:

Authorized Official
Title or Position	:	SPECIAL INSTRUCTOR (ABA)
Name	:	DMITRY MERENER
Credential	:	MS, SP ED
Telephone Number	:	646-404-4444

Provider Enumeration Date	:	10/23/2019
Last Update Date	:	10/23/2019

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