Healthcare Provider Details

I. General information

NPI: 1275734030
Provider Name (Legal Business Name): ST. THERESA'S RESIDENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S 10TH AVE
MT VERNON NY
10550-2907
US

IV. Provider business mailing address

30 S 10TH AVE
MT VERNON NY
10550-2907
US

V. Phone/Fax

Practice location:
  • Phone: 914-664-5900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number7482440
License Number StateNY

VIII. Authorized Official

Name: BRUCE ADLER
Title or Position: VICE PRESIDENT OF FINANCE
Credential:
Phone: 646-633-4710