Provider Demographics
NPI:1689733008
Name:COMMUNITY RESOURCE CENTER FOR THE DEVELOPMENTALLY DISABLED, INC.
Entity Type:Organization
Organization Name:COMMUNITY RESOURCE CENTER FOR THE DEVELOPMENTALLY DISABLED, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MEADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-292-1705
Mailing Address - Street 1:378 E 151ST ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-2603
Mailing Address - Country:US
Mailing Address - Phone:718-292-1705
Mailing Address - Fax:
Practice Address - Street 1:2253 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-2206
Practice Address - Country:US
Practice Address - Phone:718-292-1705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00357180Medicaid