Basic Information
Provider Information | |||||||||
NPI: | 1528006939 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COLLEGE PARK HEALTHCARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE WATERS OF HOUGHTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 GLEED AVE | ||||||||
Address2: | THE PARK ASSOCIATES, INC. | ||||||||
City: | EAST AURORA | ||||||||
State: | NY | ||||||||
PostalCode: | 140522980 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166522820 | ||||||||
FaxNumber: | 7166552320 | ||||||||
Practice Location | |||||||||
Address1: | 9876 LUCKEY DR | ||||||||
Address2: |   | ||||||||
City: | HOUGHTON | ||||||||
State: | NY | ||||||||
PostalCode: | 147448706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5855672207 | ||||||||
FaxNumber: | 5855672730 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2006 | ||||||||
LastUpdateDate: | 08/01/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
AuthorizedOfficialTelephone: | 7168051474 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0226301N | NY | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 2U | 01 | NY | INDEPENDENT HEALTH | OTHER | 000000315000 | 01 | NY | BLUE CROSS & BLUE SHIELD | OTHER | 01561311 | 05 | NY |   | MEDICAID | 00011370301 | 01 | NY | UNIVERA | OTHER |