Organization
LSA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. ERTUANA JORGES CASAC G (DIRECTOR)
(973) 342-9106
Entity
Organization
Contact information
Practice address
1300 AVENUE P, BROOKLYN, NY 11229-1106
(718) 645-9183
Mailing address
1300 AVENUE P, BROOKLYN, NY 11229-1106
(718) 645-9183
Taxonomy
Speciality
Code
Description
License number
State
302F00000X
Exclusive Provider Organization
Primary
261QR0401X
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
74902217
—
NY
Enumeration date
03/02/2016
Last updated
03/02/2016
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