Provider Demographics
NPI:1396822839
Name:SAMARITAN DAYTOP VILLAGE, INC.
Entity Type:Organization
Organization Name:SAMARITAN DAYTOP VILLAGE, INC.
Other - Org Name:SAMARITAN VILLAGE, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT OF HEALTH & COMM
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-764-4249
Mailing Address - Street 1:13802 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2642
Mailing Address - Country:US
Mailing Address - Phone:718-206-2000
Mailing Address - Fax:718-206-4055
Practice Address - Street 1:13020 89TH RD
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-3301
Practice Address - Country:US
Practice Address - Phone:718-441-8913
Practice Address - Fax:718-805-6041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16890324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03A0973OtherNYDS-DOH LICENSE #
NY16890OtherNYS-OASAS PROVIDER #
NY000245309Medicaid
NYPRU-393OtherNYS-OASAS PROG.REPORT#
NY080510352OtherNYS-OASAS CD OPR.CERT.
NY080510352OtherNYS-OASAS CD OPR.CERT.