Provider Demographics
NPI:1225450364
Name:LAINE NP ADULT WELLNESS CARE PC
Entity Type:Organization
Organization Name:LAINE NP ADULT WELLNESS CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSAIRE
Authorized Official - Middle Name:B
Authorized Official - Last Name:LAINE
Authorized Official - Suffix:
Authorized Official - Credentials:APN-BC
Authorized Official - Phone:973-220-8313
Mailing Address - Street 1:539 DE MOTT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1321
Mailing Address - Country:US
Mailing Address - Phone:516-223-6088
Mailing Address - Fax:
Practice Address - Street 1:539 DE MOTT AVE
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-1321
Practice Address - Country:US
Practice Address - Phone:516-223-6088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAINE ASSOCIATED INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304165-1261QC1500X
NY199824261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY173000000XOtherTAXONOMY
NJ0362301Medicaid
NY0469Medicaid
NY1104861558OtherNPI
NY1104861558OtherNPI