Provider Demographics
NPI:1952819690
Name:MORDEHACHAYEV, GOLCHEKHRA
Entity Type:Individual
Prefix:
First Name:GOLCHEKHRA
Middle Name:
Last Name:MORDEHACHAYEV
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 1:9920 63RD AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1943
Mailing Address - Country:US
Mailing Address - Phone:646-932-9105
Mailing Address - Fax:
Practice Address - Street 1:630 FLUSHING AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5026
Practice Address - Country:US
Practice Address - Phone:718-828-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY742004163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY742004OtherLICENSE NUMBER