Basic Information
| Provider Information | |||||||||
| NPI: | 1053390534 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST VINCENT DE PAUL RESIDENCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 INTERVALE AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104594240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466334774 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 INTERVALE AVENUE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9176459201 | ||||||||
| FaxNumber: | 7185897010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 03/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | COVONE | ||||||||
| AuthorizedOfficialFirstName: | ANNMARIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SRVP CFO | ||||||||
| AuthorizedOfficialTelephone: | 6466334702 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 7000366N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 01367115 | 05 | NY | MEDICAID | 01446244 | 05 | NY | MEDICAID |