Provider Demographics
NPI:1144215203
Name:LUTHERAN AUGUSTANA CENTER FOR EXTENDED CARE AND REHABILITATION
Entity Type:Organization
Organization Name:LUTHERAN AUGUSTANA CENTER FOR EXTENDED CARE AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-630-6125
Mailing Address - Street 1:5434 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-2606
Mailing Address - Country:US
Mailing Address - Phone:718-630-6125
Mailing Address - Fax:718-630-6108
Practice Address - Street 1:5434 2ND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2606
Practice Address - Country:US
Practice Address - Phone:718-630-6125
Practice Address - Fax:718-630-6108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03A0558314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00310343Medicaid
NY335521Medicare ID - Type Unspecified