Healthcare Provider Details

I. General information

NPI: 1194715870
Provider Name (Legal Business Name): LEROY VILLAGE GREEN RESIDENTIAL HEALTH CARE FACILITY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MUNSON ST
LE ROY NY
14482-8933
US

IV. Provider business mailing address

10 MUNSON ST
LE ROY NY
14482-8933
US

V. Phone/Fax

Practice location:
  • Phone: 585-768-2561
  • Fax: 585-502-0470
Mailing address:
  • Phone: 585-768-2561
  • Fax: 585-768-4335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1823300N
License Number StateNY

VIII. Authorized Official

Name: MRS. THERESA A HUBBARD
Title or Position: ACCOUNTS RECEIVABLE
Credential:
Phone: 585-502-0467