MEDICARE: FIESTA ADULT DAYCARE 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	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1952276065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIESTA ADULT DAYCARE LLC

Provider Business Mailing Address
First Line	:	2200 VICTORY BLVD FL 2
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6624
Country	:	US
Telephone Number	:	718-814-0555
Fax Number	:	718-228-8999

Provider Business Practice Location Address
First Line	:	2200 VICTORY BLVD FL 2
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6624
Country	:	US
Telephone Number	:	718-814-0555
Fax Number	:	718-228-8999

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TATYANA F ELBERG
Credential	:
Telephone Number	:	718-996-0456

Provider Enumeration Date	:	10/08/2025
Last Update Date	:	10/08/2025

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