Provider Demographics
NPI:1689864027
Name:PUERTO RICAN FAMILY LACONIA
Entity Type:Organization
Organization Name:PUERTO RICAN FAMILY LACONIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:CINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-229-6921
Mailing Address - Street 1:3050 LACONIA AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-1402
Mailing Address - Country:US
Mailing Address - Phone:212-414-7822
Mailing Address - Fax:212-691-5635
Practice Address - Street 1:145 W 15TH ST FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-6701
Practice Address - Country:US
Practice Address - Phone:212-414-7822
Practice Address - Fax:212-691-5635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY06270440315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00357135Medicaid