Basic Information
Provider Information | |||||||||
NPI: | 1982932869 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEGMAN FAMILY (GLEN FALLS) LLC V | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LANDING AT QUEENSBURY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3131 ELLIOTT AVE | ||||||||
Address2: | SUITE 500 | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981211044 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2062982909 | ||||||||
FaxNumber: | 2063014500 | ||||||||
Practice Location | |||||||||
Address1: | 27 WOODVALE RD | ||||||||
Address2: |   | ||||||||
City: | QUEENSBURY | ||||||||
State: | NY | ||||||||
PostalCode: | 128041785 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187935556 | ||||||||
FaxNumber: | 5187939863 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2009 | ||||||||
LastUpdateDate: | 12/03/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BICKEL | ||||||||
AuthorizedOfficialFirstName: | NOELLE | ||||||||
AuthorizedOfficialMiddleName: | DIAZ | ||||||||
AuthorizedOfficialTitleorPosition: | LICENSING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 2062982909 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | 750-S-003 | NY | N |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   | 310400000X | 750-S-003 | NY | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.