1174581037 NPI number — ST.DOMINIC'S HOME

Table of content: MR. ROBERT EDWARD HITCHINS III (NPI 1790378701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174581037 NPI number — ST.DOMINIC'S HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST.DOMINIC'S HOME
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:
Provider Other Organization Name Type Code:
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:
1174581037
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 WESTERN HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAUVELT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10913-2000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-359-3400
Provider Business Mailing Address Fax Number:
845-359-4253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 WESTERN HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLAUVELT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10913-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-359-3400
Provider Business Practice Location Address Fax Number:
845-359-4253
Provider Enumeration Date:
05/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KYDON
Authorized Official First Name:
JUDITH
Authorized Official Middle Name:
D
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
845-359-3400

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  07159460 , 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: 02573797 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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