Basic Information
| Provider Information | |||||||||
| NPI: | 1588603948 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SULLIVAN PARK HEALTHCARE CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE WATERS OF ENDICOTT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 301 NANTUCKET DR | ||||||||
| Address2: | |||||||||
| City: | ENDICOTT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137602735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077542705 | ||||||||
| FaxNumber: | 6077542610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7168051474 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0302301N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00949817 | 05 | NY | MEDICAID |