Provider Demographics
NPI:1609909910
Name:ELMCOR YOUTH & ADULT ACTIVITIES INC
Entity Type:Organization
Organization Name:ELMCOR YOUTH & ADULT ACTIVITIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-651-0096
Mailing Address - Street 1:3316 108TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-1224
Mailing Address - Country:US
Mailing Address - Phone:718-651-0096
Mailing Address - Fax:718-457-3932
Practice Address - Street 1:10720 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-1236
Practice Address - Country:US
Practice Address - Phone:718-651-0096
Practice Address - Fax:718-457-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02772338Medicaid