Provider Demographics
NPI:1447610290
Name:ILLIASSA INC
Entity Type:Organization
Organization Name:ILLIASSA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMBA
Authorized Official - Middle Name:
Authorized Official - Last Name:SINGHATEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-270-5436
Mailing Address - Street 1:2139 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2553
Mailing Address - Country:US
Mailing Address - Phone:646-270-5436
Mailing Address - Fax:718-901-3739
Practice Address - Street 1:2139 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2553
Practice Address - Country:US
Practice Address - Phone:646-270-5436
Practice Address - Fax:718-901-3739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY751806252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency