Provider Demographics
NPI:1457721482
Name:GRACEFUL DOVE, LLC
Entity type:Organization
Organization Name:GRACEFUL DOVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:SEDAROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-552-5179
Mailing Address - Street 1:4521 ARTHUR KILL RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1315
Mailing Address - Country:US
Mailing Address - Phone:718-552-5179
Mailing Address - Fax:718-554-4069
Practice Address - Street 1:4521 ARTHUR KILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-1315
Practice Address - Country:US
Practice Address - Phone:718-552-5179
Practice Address - Fax:718-554-4069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services