Provider Demographics
NPI:1063010767
Name:6677 BROADWAY LLC
Entity Type:Organization
Organization Name:6677 BROADWAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORUKHOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-938-7183
Mailing Address - Street 1:4718 18TH AVE STE 26
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1260
Mailing Address - Country:US
Mailing Address - Phone:718-938-7183
Mailing Address - Fax:
Practice Address - Street 1:140 BEACH 119TH ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-1953
Practice Address - Country:US
Practice Address - Phone:718-938-7183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health