Provider Demographics
NPI:1861732893
Name:SHADOW HOUSING INC
Entity type:Organization
Organization Name:SHADOW HOUSING INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-618-7337
Mailing Address - Street 1:3560 OLINVILLE AVE APT 1F
Mailing Address - Street 2:2118 WILLLIAMBRIDGE ROAD
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-5533
Mailing Address - Country:US
Mailing Address - Phone:718-618-7337
Mailing Address - Fax:646-401-7420
Practice Address - Street 1:3560 OLINVILLE AVE APT 1F
Practice Address - Street 2:2118 WILLLIAMBRIDGE ROAD
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-5533
Practice Address - Country:US
Practice Address - Phone:718-618-7337
Practice Address - Fax:646-401-7420
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASSISTANCE BY IMPROV LL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3333470176B00000X
NY33335470163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Multi-Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02382052Medicaid
NY02197271Medicaid
NY03165299Medicaid
NY01841010Medicaid