Provider Demographics
NPI:1427220698
Name:ST VICENT SERVICES GOWANUS
Entity Type:Organization
Organization Name:ST VICENT SERVICES GOWANUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENENATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-422-2204
Mailing Address - Street 1:627 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-2637
Mailing Address - Country:US
Mailing Address - Phone:718-522-3700
Mailing Address - Fax:718-488-7618
Practice Address - Street 1:66 BOERUM PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5705
Practice Address - Country:US
Practice Address - Phone:718-522-3700
Practice Address - Fax:718-488-7618
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST.VINCENT SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02287805Medicaid