Provider Demographics
NPI:1548251218
Name:QUEENS REPLACEMENT LLC
Entity type:Organization
Organization Name:QUEENS REPLACEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:LICCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-987-5942
Mailing Address - Street 1:97 NEW DORP LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2364
Mailing Address - Country:US
Mailing Address - Phone:718-448-5641
Mailing Address - Fax:718-876-5969
Practice Address - Street 1:12046 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1204
Practice Address - Country:US
Practice Address - Phone:718-793-3341
Practice Address - Fax:718-268-1666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7003264R261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02718005Medicaid
NY02718005Medicaid