Healthcare Provider Details

I. General information

NPI: 1679563464
Provider Name (Legal Business Name): NURSING CARE CENTER AT MEDFORD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 HORSEBLOCK RD
MEDFORD NY
11763
US

IV. Provider business mailing address

3115 HORSEBLOCK RD
MEDFORD NY
11763
US

V. Phone/Fax

Practice location:
  • Phone: 631-730-3016
  • Fax: 631-730-3131
Mailing address:
  • Phone: 631-730-3016
  • Fax: 631-730-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5151319N
License Number StateNY

VIII. Authorized Official

Name: MICHAEL F LEAHY
Title or Position: CONTROLLER
Credential:
Phone: 631-730-3016