Healthcare Provider Details

I. General information

NPI: 1265491922
Provider Name (Legal Business Name): IDEAL SENIOR LIVING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 HIGH AVE
ENDICOTT NY
13760-4789
US

IV. Provider business mailing address

508 HIGH AVE
ENDICOTT NY
13760-4789
US

V. Phone/Fax

Practice location:
  • Phone: 607-786-7300
  • Fax: 607-786-7417
Mailing address:
  • Phone: 607-786-7300
  • Fax: 607-786-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0303902L
License Number StateNY

VIII. Authorized Official

Name: MS. MARILYN BARBIERI
Title or Position: CONTROLLER
Credential:
Phone: 607-786-7307