Organization
ACTIVITIES OF DAILY LIVING HOME CARE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KENDRA DENISE LEWIS (CNA)
(631) 394-6639
Entity
Organization
Contact information
Practice address
67 DIANA DR, MASTIC BEACH, NY 11951-6308
(631) 394-6639
Mailing address
67 DIANA DR, MASTIC BEACH, NY 11951-6308
(631) 394-6639
Taxonomy
Speciality
Code
Description
License number
State
251E00000X
Home Health Agency
Primary
—
NY
320700000X
Physical Disabilities Residential Treatment Facility
—
NY
320800000X
Mental Illness Community Based Residential Treatment Facility
—
NY
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
—
NY
323P00000X
Psychiatric Residential Treatment Facility
—
NY
347C00000X
Private Vehicle
—
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
32-038829
MEDICAID MEDICARE
NY
Enumeration date
09/11/2012
Last updated
07/21/2022
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