Provider Demographics
NPI:1245272772
Name:SAMARITAN DAYTOP VILLAGE, INC.
Entity type:Organization
Organization Name:SAMARITAN DAYTOP VILLAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF HEALTH SERVICES & COMM BASED
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-206-2000
Mailing Address - Street 1:138-02 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:368 E 148TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4005
Practice Address - Country:US
Practice Address - Phone:718-402-2614
Practice Address - Fax:718-402-5017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132690403261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY012222191Medicaid