Healthcare Provider Details

I. General information

NPI: 1144215625
Provider Name (Legal Business Name): VILLA MARY IMMACULATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HACKETT BLVD
ALBANY NY
12208-1963
US

IV. Provider business mailing address

301 HACKETT BLVD
ALBANY NY
12208-1963
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-7600
  • Fax: 518-525-7673
Mailing address:
  • Phone: 518-525-7600
  • Fax: 518-525-7673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0101305N
License Number StateNY

VIII. Authorized Official

Name: MR. GLEN COOPER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 518-525-7670