Healthcare Provider Details

I. General information

NPI: 1053452656
Provider Name (Legal Business Name): ST. CAMILLUS RESIDENTIAL HEALTH CARE FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 FAY RD
SYRACUSE NY
13219-3009
US

IV. Provider business mailing address

813 FAY RD
SYRACUSE NY
13219-3009
US

V. Phone/Fax

Practice location:
  • Phone: 315-488-2951
  • Fax: 315-488-7734
Mailing address:
  • Phone: 315-488-2951
  • Fax: 315-488-7734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberTBI00076
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberTBI00076
License Number StateNY

VIII. Authorized Official

Name: MR. MICHAEL ZINGARO
Title or Position: CFO
Credential:
Phone: 315-703-0646