Provider Demographics
NPI:1144215625
Name:VILLA MARY IMMACULATE
Entity Type:Organization
Organization Name:VILLA MARY IMMACULATE
Other - Org Name:ST. PETER'S NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-525-7670
Mailing Address - Street 1:301 HACKETT BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1963
Mailing Address - Country:US
Mailing Address - Phone:518-525-7600
Mailing Address - Fax:518-525-7673
Practice Address - Street 1:301 HACKETT BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1963
Practice Address - Country:US
Practice Address - Phone:518-525-7600
Practice Address - Fax:518-525-7673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0101305N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00310081Medicaid
NY335128Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER