Provider Demographics
NPI:1528512589
Name:SELENA GRAD CORP
Entity type:Organization
Organization Name:SELENA GRAD CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GOROHOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-969-4510
Mailing Address - Street 1:2222 E 26TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4942
Mailing Address - Country:US
Mailing Address - Phone:917-969-4510
Mailing Address - Fax:
Practice Address - Street 1:2222 E 26TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4942
Practice Address - Country:US
Practice Address - Phone:917-969-4510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency