Healthcare Provider Details

I. General information

NPI: 1912904541
Provider Name (Legal Business Name): COUNTY OF SULLIVAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 SUNSET LAKE RD.
LIBERTY NY
12754-0671
US

IV. Provider business mailing address

PO BOX 671
LIBERTY NY
12754-0671
US

V. Phone/Fax

Practice location:
  • Phone: 845-292-8640
  • Fax: 845-513-2177
Mailing address:
  • Phone: 845-292-8640
  • Fax: 845-513-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. SHENNOY WELLINGTON
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 845-513-2129