Provider Demographics
NPI:1578171229
Name:RED DOOR THERAPEUTIC SERVICES LLC
Entity Type:Organization
Organization Name:RED DOOR THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-784-1041
Mailing Address - Street 1:535 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-7619
Mailing Address - Country:US
Mailing Address - Phone:516-385-2323
Mailing Address - Fax:516-385-5306
Practice Address - Street 1:30 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-2411
Practice Address - Country:US
Practice Address - Phone:516-385-2323
Practice Address - Fax:516-385-5306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841582764OtherNPI
1194088526OtherNPI
1740764190OtherNPI