Provider Demographics
NPI:1689856155
Name:ALFORD, ALTHEA
Entity Type:Individual
Prefix:
First Name:ALTHEA
Middle Name:
Last Name:ALFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4277 BRONX BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-0704
Mailing Address - Country:US
Mailing Address - Phone:718-519-7672
Mailing Address - Fax:
Practice Address - Street 1:4277 BRONX BOULEVARD
Practice Address - Street 2:ROOM 202
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1610
Practice Address - Country:US
Practice Address - Phone:718-519-7672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270100-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02908345Medicaid