Provider Demographics
NPI:1528609799
Name:EBDK AT CALVERTON
Entity type:Organization
Organization Name:EBDK AT CALVERTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LENAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-205-8699
Mailing Address - Street 1:67 CLINTON RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 JAN WAY
Practice Address - Street 2:
Practice Address - City:CALVERTON
Practice Address - State:NY
Practice Address - Zip Code:11933-3005
Practice Address - Country:US
Practice Address - Phone:631-508-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-30
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility