Provider Demographics
NPI:1588707079
Name:EASTERN LONG ISLAND TRANSPORTATION ENT.
Entity type:Organization
Organization Name:EASTERN LONG ISLAND TRANSPORTATION ENT.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-732-6400
Mailing Address - Street 1:46 PENTMOOR DR
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-1606
Mailing Address - Country:US
Mailing Address - Phone:631-281-0849
Mailing Address - Fax:
Practice Address - Street 1:269 MIDDLE ISLAND RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1507
Practice Address - Country:US
Practice Address - Phone:631-732-6400
Practice Address - Fax:631-732-6416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01416260Medicaid