Provider Demographics
NPI:1376292722
Name:SHOREFRONT OPERATING LLC
Entity Type:Organization
Organization Name:SHOREFRONT OPERATING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AVI
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILIPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-664-4504
Mailing Address - Street 1:3015 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-1901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3015 W 29TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1901
Practice Address - Country:US
Practice Address - Phone:718-266-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty