Provider Demographics
NPI:1023379682
Name:ANDREW LAGOMARSINO LAC
Entity type:Organization
Organization Name:ANDREW LAGOMARSINO LAC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGOMARSINO
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:347-656-6341
Mailing Address - Street 1:425 W 205TH ST
Mailing Address - Street 2:6G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-3605
Mailing Address - Country:US
Mailing Address - Phone:347-656-6341
Mailing Address - Fax:
Practice Address - Street 1:130 W 42ND ST
Practice Address - Street 2:1805
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-7902
Practice Address - Country:US
Practice Address - Phone:347-656-6341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004827261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service