Provider Demographics
NPI:1508037359
Name:PAUL J COOPER CENTER FOR HUMAN SERVICES, INC - EAST ICF
Entity Type:Organization
Organization Name:PAUL J COOPER CENTER FOR HUMAN SERVICES, INC - EAST ICF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-498-5555
Mailing Address - Street 1:519 ROCKAWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-5638
Mailing Address - Country:US
Mailing Address - Phone:718-498-5555
Mailing Address - Fax:
Practice Address - Street 1:519 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-5638
Practice Address - Country:US
Practice Address - Phone:718-498-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00625672Medicaid