Provider Demographics
NPI:1639691512
Name:VEGA, CARMEN (SERVICE COORDINATOR)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:SERVICE COORDINATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 RYERSON RD
Mailing Address - Street 2:
Mailing Address - City:NEW HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:10958-3411
Mailing Address - Country:US
Mailing Address - Phone:845-421-6675
Mailing Address - Fax:845-343-9906
Practice Address - Street 1:38 RYERSON RD
Practice Address - Street 2:
Practice Address - City:NEW HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:10958-3411
Practice Address - Country:US
Practice Address - Phone:845-421-6675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY444673171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1285031252Medicaid