Healthcare Provider Details

I. General information

NPI: 1356657423
Provider Name (Legal Business Name): NISKAYUNA OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 08/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 PROVIDENCE AVE
NISKAYUNA NY
12309-3923
US

IV. Provider business mailing address

1805 PROVIDENCE AVE
NISKAYUNA NY
12309-3923
US

V. Phone/Fax

Practice location:
  • Phone: 518-374-2212
  • Fax: 518-381-9068
Mailing address:
  • Phone: 518-374-2212
  • Fax: 518-381-9068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4652301N
License Number StateNY

VIII. Authorized Official

Name: MR. MATHEW VARGHESE
Title or Position: EXECUTIVE DIRECTOR
Credential: MSN, GNP, LNHA
Phone: 518-374-2212