Provider Demographics
NPI:1093981235
Name:THE LAKE GROVE SCHOOL
Entity Type:Organization
Organization Name:THE LAKE GROVE SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:
Authorized Official - Last Name:WIENCLAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-696-1400
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-0786
Mailing Address - Country:US
Mailing Address - Phone:631-969-1400
Mailing Address - Fax:631-716-2135
Practice Address - Street 1:3390 ROUTE 112
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1421
Practice Address - Country:US
Practice Address - Phone:631-696-1400
Practice Address - Fax:631-716-2135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINDWOOD MEADOW, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00892773Medicaid