Provider Demographics
NPI:1396441622
Name:LASANTE HEALTH CENTER INC
Entity type:Organization
Organization Name:LASANTE HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GEDALYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUMENFRUCHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-246-5700
Mailing Address - Street 1:672 PARKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-2298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:672 PARKSIDE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-2298
Practice Address - Country:US
Practice Address - Phone:718-246-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LASANTE HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-02-07
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04644657Medicaid