1326081183 NPI number — LOURDES HEALTH SUPPORT, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326081183 NPI number — LOURDES HEALTH SUPPORT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOURDES HEALTH SUPPORT, 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:
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:
1326081183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 BUTTERNUT DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
DE WITT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13214-2141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-458-3600
Provider Business Mailing Address Fax Number:
315-458-2760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1155 FRONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BINGHAMTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13905-1117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-724-0115
Provider Business Practice Location Address Fax Number:
607-724-0119
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARELLI
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
T
Authorized Official Title or Position:
EXECUTIVE DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
315-458-3600

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  7200000236 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2371222 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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