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General NPI Number Information
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NPI Number | 1811334758
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Entity Type | Organization
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Legal Business Name | SELF
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Dates
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Enumeration Date | 06/02/2013
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Last Update Date | 06/02/2013
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Provider Practice Location Address
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Address Line | 4 SPRUCE RD
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City | AMITYVILLE
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State | NY
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Zip | 11701-1019
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Country | US
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Telephone | 631-413-6210
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Fax |
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Provider Business Mailing Address
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Address Line | 4 SPRUCE RD
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City | AMITYVILLE
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State | NY
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Zip | 11701-1019
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LPN
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Name | ELCIE BESSE
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Credential |
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Telephone | 631-413-6210
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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 | 102980029
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License Number State | NY
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