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General NPI Number Information
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NPI Number | 1356657423
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Entity Type | Organization
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Legal Business Name | NISKAYUNA OPERATING CO LLC
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Dates
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Enumeration Date | 08/26/2010
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Last Update Date | 08/26/2010
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Provider Practice Location Address
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Address Line | 1805 PROVIDENCE AVE
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City | NISKAYUNA
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State | NY
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Zip | 12309-3923
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Country | US
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Telephone | 518-374-2212
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Fax | 518-381-9068
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Provider Business Mailing Address
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Address Line | 1805 PROVIDENCE AVE
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City | NISKAYUNA
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State | NY
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Zip | 12309-3923
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Country | US
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Telephone | 518-374-2212
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Fax | 518-381-9068
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. MATHEW VARGHESE
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Credential | MSN, GNP, LNHA
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Telephone | 518-374-2212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 4652301N
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License Number State | NY
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