Healthcare Provider Details

I. General information

NPI: 1336197714
Provider Name (Legal Business Name): OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 OLD VESTAL RD
VESTAL NY
13850-3531
US

IV. Provider business mailing address

4102 OLD VESTAL RD
VESTAL NY
13850-3531
US

V. Phone/Fax

Practice location:
  • Phone: 607-798-5692
  • Fax: 607-352-1738
Mailing address:
  • Phone: 607-798-5692
  • Fax: 607-352-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number0301501F
License Number StateNY

VIII. Authorized Official

Name: MR. BRIAN REGAN
Title or Position: SR VP & CFO
Credential:
Phone: 607-798-5271