MEDICARE: NURSING CARE CENTER AT MEDFORD INC

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	314000000X	Skilled Nursing Facility	5151319N	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679563464
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NURSING CARE CENTER AT MEDFORD INC

Provider Business Mailing Address
First Line	:	3115 HORSEBLOCK RD
Second Line	:
City	:	MEDFORD
State	:	NY
Zip	:	11763
Country	:	US
Telephone Number	:	631-730-3016
Fax Number	:	631-730-3131

Provider Business Practice Location Address
First Line	:	3115 HORSEBLOCK RD
Second Line	:
City	:	MEDFORD
State	:	NY
Zip	:	11763
Country	:	US
Telephone Number	:	631-730-3016
Fax Number	:	631-730-3131

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MICHAEL F LEAHY
Credential	:
Telephone Number	:	631-730-3016

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	04/14/2010

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