Basic Information
| Provider Information | |||||||||
| NPI: | 1760571939 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENDAL AT ITHACA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2230 N TRIPHAMMER RD | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148506513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072665300 | ||||||||
| FaxNumber: | 6072665353 | ||||||||
| Practice Location | |||||||||
| Address1: | 2230 N TRIPHAMMER RD | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148506513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072665300 | ||||||||
| FaxNumber: | 6072665353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | GOVERNANTI | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6072665300 | ||||||||
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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 | 5401308N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 01659250 | 05 | NY | MEDICAID |