Provider Demographics
NPI:1154795235
Name:SAMARITAN DAYTOP VILLAGE, INC.
Entity type:Organization
Organization Name:SAMARITAN DAYTOP VILLAGE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF HEALTH SERVICES &
Authorized Official - Prefix:MR
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:
Mailing Address - Fax:
Practice Address - Street 1:250 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5430
Practice Address - Country:US
Practice Address - Phone:718-292-2240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000245309Medicaid