Healthcare Provider Details

I. General information

NPI: 1043511926
Provider Name (Legal Business Name): ST DOMINIC'S HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 ANDREWS AVE
BRONX NY
10468-6001
US

IV. Provider business mailing address

500 WESTERN HIGHWAY
BLAUVELT NY
10913
US

V. Phone/Fax

Practice location:
  • Phone: 845-359-3400
  • Fax: 845-359-4023
Mailing address:
  • Phone: 845-359-3400
  • Fax: 845-359-4023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: JUDITH D KYDON
Title or Position: PRESIDENT/CEO
Credential:
Phone: 845-359-3400