Provider Demographics
NPI:1528226610
Name:CENTERLIGHT HEALTHCARE, INC
Entity Type:Organization
Organization Name:CENTERLIGHT HEALTHCARE, INC
Other - Org Name:SELECT MLTC
Other - Org Type:Other Name
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-640-6050
Mailing Address - Street 1:1250 WATERS PL
Mailing Address - Street 2:TOWER 1 SUITE 602
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2720
Mailing Address - Country:US
Mailing Address - Phone:347-640-6050
Mailing Address - Fax:
Practice Address - Street 1:1250 WATERS PL
Practice Address - Street 2:TOWER 1 SUITE 602
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2720
Practice Address - Country:US
Practice Address - Phone:347-640-6050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02710185Medicaid