Healthcare Provider Details

I. General information

NPI: 1285017095
Provider Name (Legal Business Name): LACEY FOSTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5991 EAST TAFT RD
NORTH SYRACUSE NY
13212
US

IV. Provider business mailing address

5991 EAST TAFT RD
NORTH SYRACUSE NY
13212
US

V. Phone/Fax

Practice location:
  • Phone: 315-395-7024
  • Fax:
Mailing address:
  • Phone: 315-395-7024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number297397
License Number StateNY

VIII. Authorized Official

Name: LACEY FOSTER
Title or Position: LPN
Credential:
Phone: 315-395-7024