1003920992 NPI number — AVALON GARDENS REHABILITATION & HEALTH CARE CTR LLC

Table of content: (NPI 1003920992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003920992 NPI number — AVALON GARDENS REHABILITATION & HEALTH CARE CTR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVALON GARDENS REHABILITATION & HEALTH CARE CTR LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AVALON GARDENS REHABILITATION AND HEALTH CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003920992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 ROUTE 25A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMITHTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11787-1626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-724-2200
Provider Business Mailing Address Fax Number:
631-724-2909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 ROUTE 25A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11787-1626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-724-2200
Provider Business Practice Location Address Fax Number:
631-724-2909
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OCONNOR
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
631-724-2200

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336I0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 026282 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2063005 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02569895 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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