Healthcare Provider Details

I. General information

NPI: 1023011822
Provider Name (Legal Business Name): INDIAN RIVER REHABILITATION & HEALTH CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 MADISON ST
GRANVILLE NY
12832-1221
US

IV. Provider business mailing address

17 MADISON ST
GRANVILLE NY
12832-1221
US

V. Phone/Fax

Practice location:
  • Phone: 518-642-2710
  • Fax: 518-642-1318
Mailing address:
  • Phone: 518-642-2710
  • Fax: 518-642-1318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5725302N
License Number StateNY

VIII. Authorized Official

Name: MS. RENEE M GROESBECK
Title or Position: ADMINISTRATOR
Credential:
Phone: 518-642-2710