1417084237 NPI number — ABSOLUT CENTER FOR NURSING AND REHABILITATION AT GASPORT, LLC

Table of content: (NPI 1417084237)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417084237 NPI number — ABSOLUT CENTER FOR NURSING AND REHABILITATION AT GASPORT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABSOLUT CENTER FOR NURSING AND REHABILITATION AT GASPORT, 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:
1417084237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 GLEED AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST AURORA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14052-2980
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-652-2820
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4540 LINCOLN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GASPORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14067-9212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-772-2631
Provider Business Practice Location Address Fax Number:
716-772-2054
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHERMAN
Authorized Official First Name:
ISRAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
716-652-2820

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  3158302N , 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: 000000254002 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6V . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100369 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: W4 . This is a "FAMILY CHOICE SUBACUTE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00011428902 . This is a "UNIVERA/EXCELLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01514718 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6V . This is a "FAMILY CHOICE SKILLED" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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