MEDICARE: ST DOMINIC'S HOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1043511926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST DOMINIC'S HOME

Provider Business Mailing Address
First Line	:	500 WESTERN HIGHWAY
Second Line	:
City	:	BLAUVELT
State	:	NY
Zip	:	10913
Country	:	US
Telephone Number	:	845-359-3400
Fax Number	:	845-359-4023

Provider Business Practice Location Address
First Line	:	2340 ANDREWS AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-6001
Country	:	US
Telephone Number	:	845-359-3400
Fax Number	:	845-359-4023

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	JUDITH D KYDON
Credential	:
Telephone Number	:	845-359-3400

Provider Enumeration Date	:	11/09/2010
Last Update Date	:	12/28/2016

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