Provider Demographics
NPI:1265533079
Name:CONNETQUOT WEST, INC.
Entity type:Organization
Organization Name:CONNETQUOT WEST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-844-0055
Mailing Address - Street 1:200 ALLEN BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-5637
Mailing Address - Country:US
Mailing Address - Phone:631-844-0055
Mailing Address - Fax:631-844-9095
Practice Address - Street 1:200 ALLEN BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-5637
Practice Address - Country:US
Practice Address - Phone:631-844-0055
Practice Address - Fax:631-844-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01426939Medicaid
PA0019095560002Medicaid
NJ8560803Medicaid
NY=========-002OtherHEALTH FIRST NEW YORK
0752710001Medicare ID - Type Unspecified