Basic Information
| Provider Information | |||||||||
| NPI: | 1023162211 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LORETTO UTICA RESIDENTIAL HEALTH CARE FACILITY | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1445 KEMBLE ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135014441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157320100 | ||||||||
| FaxNumber: | 3157335718 | ||||||||
| Practice Location | |||||||||
| Address1: | 1445 KEMBLE ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135014441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157320100 | ||||||||
| FaxNumber: | 3157335718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 03/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | SYNOKOWSKI | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRETOR | ||||||||
| AuthorizedOfficialTelephone: | 3157320100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | ADMINISTRATOR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 03A1629 | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 01640904 | 05 | NY | MEDICAID | 01640913 | 05 | NY | MEDICAID |