Provider Demographics
NPI:1700033149
Name:HOME AND COMMUNITY BASED SERVICES
Entity Type:Organization
Organization Name:HOME AND COMMUNITY BASED SERVICES
Other - Org Name:HOME BASED COMMUNITY WAIVER PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING/CREDENTIALING MGR.
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-746-0350
Mailing Address - Street 1:377 OAK STREET
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4633
Mailing Address - Country:US
Mailing Address - Phone:516-746-0350
Mailing Address - Fax:516-877-1305
Practice Address - Street 1:377 OAK STREET
Practice Address - Street 2:5TH FLOOR
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-6542
Practice Address - Country:US
Practice Address - Phone:516-746-0350
Practice Address - Fax:516-565-6095
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY AND CHILDREN'S ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-27
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01303566Medicaid