=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275849341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENSSELAER OPERATING CO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2010
-----------------------------------------------------
Last Update Date | 08/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 284 TROY RD
-----------------------------------------------------
City | RENSSELAER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12144-9474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-286-1621
-----------------------------------------------------
Fax | 518-286-1691
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 284 TROY RD
-----------------------------------------------------
City | RENSSELAER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12144-9474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-286-1621
-----------------------------------------------------
Fax | 518-286-1691
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. MATHEW VARGHESE
-----------------------------------------------------
Credential | MSN, GNP, LNHA
-----------------------------------------------------
Telephone | 518-374-2212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 4152302N
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------