Basic Information
| Provider Information | |||||||||
| NPI: | 1457402505 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEWIS COUNTY GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LCGH CERTIFIED HOME HEALTH CARE AGENCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7785 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | LOWVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133671229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153765200 | ||||||||
| FaxNumber: | 3153769317 | ||||||||
| Practice Location | |||||||||
| Address1: | 7785 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | LOWVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133671229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153765200 | ||||||||
| FaxNumber: | 3153769317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | PRINCE | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 3153765203 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 2424600 | NY | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 00321944 | 05 | NY | MEDICAID |