Provider Demographics
NPI:1598206641
Name:SEA CREST ACQUISITION II, LLC
Entity Type:Organization
Organization Name:SEA CREST ACQUISITION II, LLC
Other - Org Name:SEA CREST DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER / MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PASQUALE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBENEDICTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-422-7818
Mailing Address - Street 1:3035 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-2114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3035 W 24TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-2114
Practice Address - Country:US
Practice Address - Phone:516-422-7817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1111261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
332763OtherCCN