Basic Information
Provider Information | |||||||||
NPI: | 1013443498 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLR GLENS FALLS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GLENS FALLS CENTER FOR REHABILITATION AND NURSING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4770 WHITE PLAINS RD | ||||||||
Address2: |   | ||||||||
City: | BRONX | ||||||||
State: | NY | ||||||||
PostalCode: | 104701104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189319700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 152 UPPER SHERMAN AVE | ||||||||
Address2: |   | ||||||||
City: | GLENS FALLS | ||||||||
State: | NY | ||||||||
PostalCode: | 128042746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187932575 | ||||||||
FaxNumber: | 5187930563 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2017 | ||||||||
LastUpdateDate: | 07/24/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ABRAMCHIK | ||||||||
AuthorizedOfficialFirstName: | AMIR | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
AuthorizedOfficialTelephone: | 7189319700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5601306N | NY | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 00360458 | 05 | NY |   | MEDICAID |