Provider Demographics
NPI:1043375355
Name:GRAND FAMILY IMMEDIATE MEDICAL CARE
Entity Type:Organization
Organization Name:GRAND FAMILY IMMEDIATE MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BENCHABBAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-218-8357
Mailing Address - Street 1:678 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-4937
Mailing Address - Country:US
Mailing Address - Phone:718-218-8357
Mailing Address - Fax:
Practice Address - Street 1:678 GRAND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-4937
Practice Address - Country:US
Practice Address - Phone:718-218-8357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1825141173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01332223Medicaid
NY67F381Medicare ID - Type Unspecified
NY01332223Medicaid