Provider Demographics
NPI:1891219135
Name:MASSAPEQUA CENTER LLC
Entity type:Organization
Organization Name:MASSAPEQUA CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:FUCHS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-888-5200
Mailing Address - Street 1:101 LOUDEN AVE.
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-1705
Mailing Address - Country:US
Mailing Address - Phone:631-264-0222
Mailing Address - Fax:
Practice Address - Street 1:101 LOUDEN AVE.
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-1705
Practice Address - Country:US
Practice Address - Phone:631-264-0222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01605545Medicaid