Provider Demographics
NPI:1174994305
Name:ELMCOR YOUTH AND ADULT ACTIVITIES
Entity type:Organization
Organization Name:ELMCOR YOUTH AND ADULT ACTIVITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROPO
Authorized Official - Middle Name:
Authorized Official - Last Name:OYEBODE
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER IN ACCOUTING
Authorized Official - Phone:718-651-0096
Mailing Address - Street 1:10720 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-1236
Mailing Address - Country:US
Mailing Address - Phone:718-651-0096
Mailing Address - Fax:718-457-3932
Practice Address - Street 1:10720 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-1236
Practice Address - Country:US
Practice Address - Phone:718-651-0096
Practice Address - Fax:718-457-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180711300324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid