Provider Demographics
NPI:1336675776
Name:RAFAILOV, ELCHIN (LIVERY CAR SERVICE)
Entity Type:Individual
Prefix:MR
First Name:ELCHIN
Middle Name:
Last Name:RAFAILOV
Suffix:
Gender:M
Credentials:LIVERY CAR SERVICE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1659 BATH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1659 BATH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-4509
Practice Address - Country:US
Practice Address - Phone:212-920-0133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYB02920405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY47-4929209Medicaid