Provider Demographics
NPI:1013150531
Name:ICL GARDEN HOUSE (AVE D) ICF
Entity type:Organization
Organization Name:ICL GARDEN HOUSE (AVE D) ICF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BACCHUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-385-3030
Mailing Address - Street 1:4715 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5817
Mailing Address - Country:US
Mailing Address - Phone:718-451-2817
Mailing Address - Fax:
Practice Address - Street 1:4715 AVENUE D
Practice Address - Street 2:ICL GARDEN HOUSE (AVE D) ICF
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203
Practice Address - Country:US
Practice Address - Phone:718-451-2817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid