Provider Demographics
NPI:1679903470
Name:MELVILLE SC, LLC
Entity type:Organization
Organization Name:MELVILLE SC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:631-293-9700
Mailing Address - Street 1:1895 WALT WHITMAN RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3031
Mailing Address - Country:US
Mailing Address - Phone:631-293-9700
Mailing Address - Fax:631-293-2021
Practice Address - Street 1:1895 WALT WHITMAN RD
Practice Address - Street 2:SUITE 10
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3031
Practice Address - Country:US
Practice Address - Phone:631-293-9700
Practice Address - Fax:631-293-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5153209R261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33D0654179OtherCLIA
NY01287085Medicaid
NY33D0654179OtherCLIA
NY5153209RMedicare Oscar/Certification