MEDICARE: ISLAND REHABILITATIVE SERVICES/B'KLYN

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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center		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	:	1790779114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND REHABILITATIVE SERVICES/B'KLYN

Provider Business Mailing Address
First Line	:	2031-10 FOREST AVE
Second Line	:	ISLAND REHABILITATIVE SERVICES
City	:	STATEN ISLAND
State	:	NY
Zip	:	10303-1796
Country	:	US
Telephone Number	:	718-448-5641
Fax Number	:	718-448-6117

Provider Business Practice Location Address
First Line	:	5918-5924 13TH AVE
Second Line	:	ISLAND REHABILITATIVE SERVICES/B'KLYN
City	:	BROOKLYN
State	:	NY
Zip	:	11219
Country	:	US
Telephone Number	:	718-437-1594
Fax Number	:	718-437-5092

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DOMINIC LICCIARDI
Credential	:
Telephone Number	:	718-437-1594

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	07/21/2022

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