Provider Demographics
NPI:1790779114
Name:ISLAND REHABILITATIVE SERVICES/B'KLYN
Entity Type:Organization
Organization Name:ISLAND REHABILITATIVE SERVICES/B'KLYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:LICCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-437-1594
Mailing Address - Street 1:2031-10 FOREST AVE
Mailing Address - Street 2:ISLAND REHABILITATIVE SERVICES
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-1796
Mailing Address - Country:US
Mailing Address - Phone:718-448-5641
Mailing Address - Fax:718-448-6117
Practice Address - Street 1:5918-5924 13TH AVE
Practice Address - Street 2:ISLAND REHABILITATIVE SERVICES/B'KLYN
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219
Practice Address - Country:US
Practice Address - Phone:718-437-1594
Practice Address - Fax:718-437-5092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00519755Medicaid
NY00519755Medicaid