Provider Demographics
NPI:1205822400
Name:OUR LADY OF CONSOLATION CARE CENTER
Entity Type:Organization
Organization Name:OUR LADY OF CONSOLATION CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE CONTINUING CARE
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-862-3951
Mailing Address - Street 1:111 BEACH DR
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4929
Mailing Address - Country:US
Mailing Address - Phone:631-587-1600
Mailing Address - Fax:631-587-3263
Practice Address - Street 1:111 BEACH DR
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4929
Practice Address - Country:US
Practice Address - Phone:631-587-1600
Practice Address - Fax:631-587-3263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5154319N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY62124OtherVYTRA PROVIDER #
NY00311440Medicaid
NY007932OtherBLUE CROSS PROVIDER #
NYA940385OtherOXFORD PROVIDER #
NYA940385OtherOXFORD PROVIDER #