Provider Demographics
NPI:1073936258
Name:SECOND HOME OF LONG ISLAND LLC
Entity Type:Organization
Organization Name:SECOND HOME OF LONG ISLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SERGE
Authorized Official - Middle Name:
Authorized Official - Last Name:DYMERETS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-400-0910
Mailing Address - Street 1:336 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-3907
Mailing Address - Country:US
Mailing Address - Phone:516-590-0022
Mailing Address - Fax:
Practice Address - Street 1:336 FULTON AVE
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-3907
Practice Address - Country:US
Practice Address - Phone:516-590-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care