Provider Demographics
NPI:1669925533
Name:ROCKAWAY KIDNEY CENTER LLC
Entity type:Organization
Organization Name:ROCKAWAY KIDNEY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:OLUSEGUN
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNFOWORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-770-5712
Mailing Address - Street 1:529 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3645
Mailing Address - Country:US
Mailing Address - Phone:516-770-5712
Mailing Address - Fax:718-228-8036
Practice Address - Street 1:529 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3645
Practice Address - Country:US
Practice Address - Phone:516-770-5712
Practice Address - Fax:718-228-8036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty