Provider Demographics
NPI:1992167860
Name:ROUSSEAU ETIENNE
Entity type:Organization
Organization Name:ROUSSEAU ETIENNE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MR
Authorized Official - First Name:ROUSSEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-335-7427
Mailing Address - Street 1:1695 REMSEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5233
Mailing Address - Country:US
Mailing Address - Phone:917-335-7427
Mailing Address - Fax:718-287-4600
Practice Address - Street 1:1695 REMSEN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5233
Practice Address - Country:US
Practice Address - Phone:917-335-7427
Practice Address - Fax:718-287-4300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid