Provider Demographics
NPI:1104861541
Name:BRONXCARE SPECIAL CARE CENTER
Entity Type:Organization
Organization Name:BRONXCARE SPECIAL CARE CENTER
Other - Org Name:BRONXCARE SPECIAL CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:DEMARCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-901-8600
Mailing Address - Street 1:1265 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-3401
Mailing Address - Country:US
Mailing Address - Phone:718-579-7006
Mailing Address - Fax:
Practice Address - Street 1:1276 FULTON AVE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456
Practice Address - Country:US
Practice Address - Phone:718-579-7006
Practice Address - Fax:718-579-7401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0256093336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01350930Medicaid
2059731OtherPK