Provider Demographics
NPI:1275977027
Name:EASTSIDE SERVICES (NEW LIFE CENTER), LLC
Entity Type:Organization
Organization Name:EASTSIDE SERVICES (NEW LIFE CENTER), LLC
Other - Org Name:ESNLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SANYALE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MPH,MS
Authorized Official - Phone:917-864-1233
Mailing Address - Street 1:2425 23RD ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2837
Mailing Address - Country:US
Mailing Address - Phone:917-864-1233
Mailing Address - Fax:
Practice Address - Street 1:2425 23RD ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2837
Practice Address - Country:US
Practice Address - Phone:917-864-1233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00000000251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00000000OtherSUBCONTRACT CLINICAL SERVICES