Provider Demographics
NPI:1184661290
Name:THE SHIELD OF DAVID, INC.
Entity Type:Organization
Organization Name:THE SHIELD OF DAVID, INC.
Other - Org Name:THE SHIELD INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENZANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-886-1682
Mailing Address - Street 1:144-61 ROOSEVELT AVENUE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3909 214TH PL
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2123
Practice Address - Country:US
Practice Address - Phone:718-269-2004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6593164261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00243949Medicaid
NY03668Medicare ID - Type UnspecifiedFISCAL INTERMEDIARY GHI