Provider Demographics
NPI:1568619294
Name:WEST NASSAU COMMUNITY RESIDENCE
Entity Type:Organization
Organization Name:WEST NASSAU COMMUNITY RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:VASSALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-746-0350
Mailing Address - Street 1:100 E OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4633
Mailing Address - Country:US
Mailing Address - Phone:516-745-0350
Mailing Address - Fax:516-877-1305
Practice Address - Street 1:505 ELMONT RD
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-4028
Practice Address - Country:US
Practice Address - Phone:516-285-1511
Practice Address - Fax:516-285-0983
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY AND CHILDREN'S ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9206008320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01681281Medicaid