Provider Demographics
NPI:1558572750
Name:QUEENS VILLAGE INC.
Entity Type:Organization
Organization Name:QUEENS VILLAGE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:KUCHARNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-918-2233
Mailing Address - Street 1:9623 SPRINGFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1327
Mailing Address - Country:US
Mailing Address - Phone:718-776-8787
Mailing Address - Fax:718-776-6101
Practice Address - Street 1:9623 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1327
Practice Address - Country:US
Practice Address - Phone:718-776-8787
Practice Address - Fax:718-776-6101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-28
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYB00031344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02867009Medicaid