Provider Demographics
NPI:1982878757
Name:SAMARITAN DAYTOP VILLAGE, INC.
Entity Type:Organization
Organization Name:SAMARITAN DAYTOP VILLAGE, INC.
Other - Org Name:SAMARITAN VILLAGE, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VP OF HEALTH SERVICES & COMMUNITY B
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:718-206-2000
Mailing Address - Street 1:13802 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2642
Mailing Address - Country:US
Mailing Address - Phone:718-206-2000
Mailing Address - Fax:718-206-4055
Practice Address - Street 1:14401 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-3601
Practice Address - Country:US
Practice Address - Phone:718-206-1990
Practice Address - Fax:718-206-0051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080311278261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY080311278OtherOASAS LIC#
NY16890OtherOASAS PROVIDER #
NY000245309Medicaid
NYPRU #6595OtherOASAS PROG,REPORT #