Provider Demographics
NPI:1467749630
Name:PROVISION AT NEW YORK LLC
Entity Type:Organization
Organization Name:PROVISION AT NEW YORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:Y
Authorized Official - Last Name:CHU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-780-7862
Mailing Address - Street 1:7285 YELLOWSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4133
Mailing Address - Country:US
Mailing Address - Phone:718-760-7862
Mailing Address - Fax:718-760-7861
Practice Address - Street 1:6135 JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2771
Practice Address - Country:US
Practice Address - Phone:718-760-7862
Practice Address - Fax:718-760-7861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006676261Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU99180Medicare UPIN