Provider Demographics
NPI:1871798710
Name:55 SANDALWOOD ENTERPRISES INC
Entity type:Organization
Organization Name:55 SANDALWOOD ENTERPRISES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-284-2299
Mailing Address - Street 1:818 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2563
Mailing Address - Country:US
Mailing Address - Phone:631-284-2299
Mailing Address - Fax:631-284-2305
Practice Address - Street 1:3400 BAINBRIDGE AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-4333
Practice Address - Fax:718-547-2907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM8W601OtherMEDICARE PTAN
NY2527580Medicaid
NYM8W601Medicare PIN