Healthcare Provider Details

I. General information

NPI: 1063411262
Provider Name (Legal Business Name): PROVIDENCE REST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 WATERBURY AVE
BRONX NY
10465-1554
US

IV. Provider business mailing address

3304 WATERBURY AVE
BRONX NY
10465-1554
US

V. Phone/Fax

Practice location:
  • Phone: 718-931-3000
  • Fax: 718-514-8447
Mailing address:
  • Phone: 718-931-3000
  • Fax: 718-514-8447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number7000306N
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number7000306N
License Number StateNY

VIII. Authorized Official

Name: MS. SUSAN M STEINBERG
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 718-931-3000