Healthcare Provider Details

I. General information

NPI: 1669692448
Provider Name (Legal Business Name): EXTENDACARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

646 MAIN ST
PORT JEFFERSON NY
11777-2235
US

IV. Provider business mailing address

646 MAIN ST
PORT JEFFERSON NY
11777-2235
US

V. Phone/Fax

Practice location:
  • Phone: 631-473-1317
  • Fax: 631-473-1337
Mailing address:
  • Phone: 631-473-1317
  • Fax: 631-473-1337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number9589L001
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number9589L001
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number9589L001
License Number StateNY

VIII. Authorized Official

Name: MR. BRUCE A UVEGES
Title or Position: ADMINISTRATOR
Credential:
Phone: 631-473-1317