Provider Demographics
NPI:1811347057
Name:BLACK DIAMOND ROSLYN, INC.
Entity type:Organization
Organization Name:BLACK DIAMOND ROSLYN, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:BALBERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-719-5999
Mailing Address - Street 1:754 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4929
Mailing Address - Country:US
Mailing Address - Phone:516-719-5999
Mailing Address - Fax:516-719-5997
Practice Address - Street 1:754 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4929
Practice Address - Country:US
Practice Address - Phone:516-719-5999
Practice Address - Fax:516-719-5997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-19
Last Update Date:2016-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2367L253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care