Healthcare Provider Details

I. General information

NPI: 1063134294
Provider Name (Legal Business Name): SJ3 OP DIVERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3002 N 18TH ST
SAINT JOSEPH MO
64505-1872
US

IV. Provider business mailing address

525 CHESTNUT ST STE 102
CEDARHURST NY
11516-2223
US

V. Phone/Fax

Practice location:
  • Phone: 516-364-4200
  • Fax:
Mailing address:
  • Phone: 516-727-1634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL GOLDNER
Title or Position: AUTHORIZED PERSON
Credential:
Phone: 516-727-1634