Healthcare Provider Details

I. General information

NPI: 1780825851
Provider Name (Legal Business Name): LONG ISLAND STATE VETERANS HOME SUNY AT STONY BROOK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PATRIOTS RD
STONY BROOK NY
11790-3318
US

IV. Provider business mailing address

100 PATRIOTS RD
STONY BROOK NY
11790-3318
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-8500
  • Fax: 631-444-8575
Mailing address:
  • Phone: 631-444-8500
  • Fax: 631-444-8575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5151310N
License Number StateNY

VIII. Authorized Official

Name: MR. FRED SGANGA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 631-444-8500