Basic Information
Provider Information | |||||||||
NPI: | 1700848447 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OUR LADY OF CONSOLATION GERIATRIC CARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 111 BEACH DR | ||||||||
Address2: |   | ||||||||
City: | WEST ISLIP | ||||||||
State: | NY | ||||||||
PostalCode: | 117954929 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6315871600 | ||||||||
FaxNumber: | 6315873263 | ||||||||
Practice Location | |||||||||
Address1: | 111 BEACH DR | ||||||||
Address2: |   | ||||||||
City: | WEST ISLIP | ||||||||
State: | NY | ||||||||
PostalCode: | 117954929 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6315871600 | ||||||||
FaxNumber: | 6315873263 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2006 | ||||||||
LastUpdateDate: | 03/23/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAIGHT | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 6314656442 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 5154901L | NY | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 00830355 | 05 | NY |   | MEDICAID | 5154901L | 01 | NY | OPERATING CERTIFICATE # | OTHER |