Provider Demographics
NPI:1619539996
Name:QUEENS BOULEVARD EXTENDED CARE FACILITY DIALYSIS CENTER LLC
Entity type:Organization
Organization Name:QUEENS BOULEVARD EXTENDED CARE FACILITY DIALYSIS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-205-0287
Mailing Address - Street 1:6111 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4965
Mailing Address - Country:US
Mailing Address - Phone:718-205-0287
Mailing Address - Fax:
Practice Address - Street 1:6111 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4965
Practice Address - Country:US
Practice Address - Phone:718-205-0287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-08
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment