Provider Demographics
NPI:1033593488
Name:BEACON
Entity Type:Organization
Organization Name:BEACON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BEATON-FUNG
Authorized Official - Suffix:
Authorized Official - Credentials:BS/CDN/CLC
Authorized Official - Phone:917-750-4929
Mailing Address - Street 1:14838 HUXLEY ST
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2720
Mailing Address - Country:US
Mailing Address - Phone:917-750-4929
Mailing Address - Fax:
Practice Address - Street 1:14838 HUXLEY ST
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-2720
Practice Address - Country:US
Practice Address - Phone:917-750-4929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004244-1253Z00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY004244-1OtherAGENCY