Provider Demographics
NPI:1679977680
Name:99-04 57TH AVENUE, INC.
Entity type:Organization
Organization Name:99-04 57TH AVENUE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:ACEBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-760-0471
Mailing Address - Street 1:9904 57TH AVE
Mailing Address - Street 2:SUITE LH
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-3746
Mailing Address - Country:US
Mailing Address - Phone:718-760-0471
Mailing Address - Fax:
Practice Address - Street 1:9904 57TH AVE
Practice Address - Street 2:SUITE LH
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-3746
Practice Address - Country:US
Practice Address - Phone:718-760-0471
Practice Address - Fax:718-760-4739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0438701261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental