Provider Demographics
NPI:1609383389
Name:RISEWELL COMMUNITY SERVICES
Entity type:Organization
Organization Name:RISEWELL COMMUNITY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:631-669-5355
Mailing Address - Street 1:1 ROUTE 109 FARMINGDALE ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6424
Mailing Address - Country:US
Mailing Address - Phone:631-669-5355
Mailing Address - Fax:631-669-1114
Practice Address - Street 1:3390 ROUTE 112 STE B
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763
Practice Address - Country:US
Practice Address - Phone:631-512-4092
Practice Address - Fax:631-698-0137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02716952Medicaid