Provider Demographics
NPI:1083341127
Name:1377 EAST 17TH STREET LLC
Entity Type:Organization
Organization Name:1377 EAST 17TH STREET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSIF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-802-8558
Mailing Address - Street 1:3626 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-1647
Mailing Address - Country:US
Mailing Address - Phone:717-802-8558
Mailing Address - Fax:
Practice Address - Street 1:3626 BAYVIEW AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1647
Practice Address - Country:US
Practice Address - Phone:718-802-8558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1377 EAST 17TH STREET LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)