Provider Demographics
NPI:1588961122
Name:PHASE PIGGY BACK, INC
Entity type:Organization
Organization Name:PHASE PIGGY BACK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-690-4002
Mailing Address - Street 1:266 WEST 145TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10039-4104
Mailing Address - Country:US
Mailing Address - Phone:212-690-4002
Mailing Address - Fax:212-690-3264
Practice Address - Street 1:266 W 145TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10039-4104
Practice Address - Country:US
Practice Address - Phone:212-690-4002
Practice Address - Fax:212-690-3264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01992841Medicaid