Provider Demographics
NPI:1669636577
Name:COMPREHENSIVE COMMUITY DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:COMPREHENSIVE COMMUITY DEVELOPMENT CORPORATION
Other - Org Name:DIALLO MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPADA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:718-589-2232
Mailing Address - Street 1:731 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2631
Mailing Address - Country:US
Mailing Address - Phone:718-589-8324
Mailing Address - Fax:718-860-1838
Practice Address - Street 1:1760 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-3022
Practice Address - Country:US
Practice Address - Phone:718-892-8474
Practice Address - Fax:718-892-4311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMPREHENSIVE COMMUNITY DEVELOPMENT CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-10
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7000239R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00665274Medicaid
NY00665274Medicaid