Provider Demographics
NPI:1235130840
Name:ISLAND REHABILITATIVE SERVICES CORP.
Entity Type:Organization
Organization Name:ISLAND REHABILITATIVE SERVICES CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:LICCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-987-5942
Mailing Address - Street 1:97 NEW DORP LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2364
Mailing Address - Country:US
Mailing Address - Phone:718-448-5641
Mailing Address - Fax:718-876-5969
Practice Address - Street 1:470 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3401
Practice Address - Country:US
Practice Address - Phone:718-987-5942
Practice Address - Fax:718-667-9708
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISLAND REHABILITATIVE SERVICES CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00519755Medicaid
NY00519755Medicaid