Healthcare Provider Details

I. General information

NPI: 1417952417
Provider Name (Legal Business Name): CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 FANNING ST
STATEN ISLAND NY
10314-5307
US

IV. Provider business mailing address

25 FANNING ST
STATEN ISLAND NY
10314-5307
US

V. Phone/Fax

Practice location:
  • Phone: 718-289-7900
  • Fax: 718-289-7028
Mailing address:
  • Phone: 718-289-7900
  • Fax: 718-289-7028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number7004305N
License Number StateNY

VIII. Authorized Official

Name: MS. LORRI ANN SCULLIN-SENK
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 718-289-7890