Healthcare Provider Details

I. General information

NPI: 1740356559
Provider Name (Legal Business Name): LEILANI RAGUCKAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4396 COUNTY ROUTE 10
DE PEYSTER NY
13633-0023
US

IV. Provider business mailing address

PO BOX 23
DE PEYSTER NY
13633-0023
US

V. Phone/Fax

Practice location:
  • Phone: 315-344-6604
  • Fax:
Mailing address:
  • Phone: 315-344-6604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number557596
License Number StateNY

VIII. Authorized Official

Name: LEILANI RAGUCKAS
Title or Position: OWNER
Credential: RN
Phone: 315-344-6604