Provider Demographics
NPI:1194085662
Name:ROCKAWAY HD LLC
Entity type:Organization
Organization Name:ROCKAWAY HD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUSEGUN
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNFOWORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-327-4503
Mailing Address - Street 1:529 BEACH 20TH STREET
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3645
Mailing Address - Country:US
Mailing Address - Phone:718-327-4503
Mailing Address - Fax:718-327-0043
Practice Address - Street 1:529 BEACH 20TH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3645
Practice Address - Country:US
Practice Address - Phone:718-327-7307
Practice Address - Fax:718-327-3297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-18
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206115261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment