Healthcare Provider Details

I. General information

NPI: 1518037837
Provider Name (Legal Business Name): ST. JOHNLAND NURSING CENTER , INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 SUNKEN MEADOW RD
KINGS PARK NY
11754-1000
US

IV. Provider business mailing address

395 SUNKEN MEADOW RD
KINGS PARK NY
11754-1000
US

V. Phone/Fax

Practice location:
  • Phone: 631-269-5800
  • Fax: 631-269-5876
Mailing address:
  • Phone: 631-269-5800
  • Fax: 631-269-5876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number5157311N
License Number StateNY

VIII. Authorized Official

Name: MRS. MARY JEAN WEBER
Title or Position: CEO - ADMINISTRATOR
Credential: LNHA
Phone: 631-269-5800