Provider Demographics
NPI:1740617315
Name:FAITH MISSION ALCOHOL CRISIS CENTER
Entity type:Organization
Organization Name:FAITH MISSION ALCOHOL CRISIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-322-3455
Mailing Address - Street 1:114-40 VAN WYCK EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420
Mailing Address - Country:US
Mailing Address - Phone:718-322-3455
Mailing Address - Fax:718-848-4152
Practice Address - Street 1:114-40 VAN WYCK EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420
Practice Address - Country:US
Practice Address - Phone:718-322-3455
Practice Address - Fax:718-848-4152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140710094324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility