Provider Demographics
NPI:1154789683
Name:AWIXA HOME OF LI, INC
Entity type:Organization
Organization Name:AWIXA HOME OF LI, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALYSE
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:CARDELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-882-9492
Mailing Address - Street 1:301 CLEARVIEW LN
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-8505
Mailing Address - Country:US
Mailing Address - Phone:516-882-9492
Mailing Address - Fax:516-882-9494
Practice Address - Street 1:199 BENTON PL
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-1507
Practice Address - Country:US
Practice Address - Phone:516-882-9492
Practice Address - Fax:516-882-9494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization