Provider Demographics
NPI:1497981328
Name:THE PAC PROGRAM OF THE BRONX
Entity Type:Organization
Organization Name:THE PAC PROGRAM OF THE BRONX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:718-328-2605
Mailing Address - Street 1:1215 STRATFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-2501
Mailing Address - Country:US
Mailing Address - Phone:718-328-2605
Mailing Address - Fax:718-328-2609
Practice Address - Street 1:1215 STRATFORD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-2501
Practice Address - Country:US
Practice Address - Phone:718-328-2605
Practice Address - Fax:718-328-2609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100411691261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY100411691OtherNEW YORK STATE OPERATING CERTIFICATE