Provider Demographics
NPI:1164475133
Name:FAR ROCKAWAY VA CLINIC
Entity Type:Organization
Organization Name:FAR ROCKAWAY VA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-254-0339
Mailing Address - Street 1:1288 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3909
Mailing Address - Country:US
Mailing Address - Phone:718-945-7150
Mailing Address - Fax:718-634-2155
Practice Address - Street 1:1288 CENTRAL AVE
Practice Address - Street 2:1288 CENTRAL AVE.
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3909
Practice Address - Country:US
Practice Address - Phone:718-945-7150
Practice Address - Fax:718-634-2155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA