Provider Demographics
NPI:1841468980
Name:LAKE GROVE MAPLE VALLEY
Entity type:Organization
Organization Name:LAKE GROVE MAPLE VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:
Authorized Official - Last Name:WIENCLAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-696-1400
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-0786
Mailing Address - Country:US
Mailing Address - Phone:631-716-2127
Mailing Address - Fax:631-716-2135
Practice Address - Street 1:6 FARLEY RD
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:MA
Practice Address - Zip Code:01379-9706
Practice Address - Country:US
Practice Address - Phone:978-544-6913
Practice Address - Fax:978-544-8672
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINDWOOD MEADOW
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251S00000XAgenciesCommunity/Behavioral Health