Provider Demographics
NPI:1063637817
Name:LOWER EASTSIDE SERVICE CENTER, INC.
Entity Type:Organization
Organization Name:LOWER EASTSIDE SERVICE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, CFO-CIO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:HUNTER
Authorized Official - Last Name:PAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-566-7713
Mailing Address - Street 1:80 MAIDEN LN
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-4811
Mailing Address - Country:US
Mailing Address - Phone:212-566-5372
Mailing Address - Fax:
Practice Address - Street 1:46 E BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-6803
Practice Address - Country:US
Practice Address - Phone:212-343-3533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00245689251S00000X, 261QM0801X, 261QM2800X, 261QP2300X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00245689Medicaid