Healthcare Provider Details

I. General information

NPI: 1780989640
Provider Name (Legal Business Name): FAXTON ST. LUKE'S HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1676 SUNSET AVE
UTICA NY
13502-5416
US

IV. Provider business mailing address

1676 SUNSET AVE
UTICA NY
13502-5416
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-5455
  • Fax:
Mailing address:
  • Phone: 315-624-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number019988-1
License Number StateNY

VIII. Authorized Official

Name: JANET L. BAKER
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: MA, CCC-SLP
Phone: 802-338-1179