Provider Demographics
NPI:1619128915
Name:ROOSEVELT CHILDRENS CENTER
Entity Type:Organization
Organization Name:ROOSEVELT CHILDRENS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:315-331-5001
Mailing Address - Street 1:848 PEIRSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEWARK N
Mailing Address - State:NY
Mailing Address - Zip Code:14513-9762
Mailing Address - Country:US
Mailing Address - Phone:315-331-2086
Mailing Address - Fax:
Practice Address - Street 1:848 PEIRSON AVENUE
Practice Address - Street 2:
Practice Address - City:NEWARK N
Practice Address - State:NY
Practice Address - Zip Code:14513-9762
Practice Address - Country:US
Practice Address - Phone:315-331-2086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY444295-1251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health