Provider Demographics
NPI:1235256256
Name:FIVE TOWNS COMMUNITY CENTER CODA PROGRAM
Entity Type:Organization
Organization Name:FIVE TOWNS COMMUNITY CENTER CODA PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:SISTRUNK
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:516-239-6244
Mailing Address - Street 1:270 LAWRENCE AVE
Mailing Address - Street 2:CODA PROGRAM
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1224
Mailing Address - Country:US
Mailing Address - Phone:516-239-6244
Mailing Address - Fax:516-371-2147
Practice Address - Street 1:270 LAWRENCE AVE
Practice Address - Street 2:CODA PROGRAM
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1224
Practice Address - Country:US
Practice Address - Phone:516-239-6244
Practice Address - Fax:516-371-2147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02784169Medicaid