Provider Demographics
NPI:1275849341
Name:RENSSELAER OPERATING CO LLC
Entity Type:Organization
Organization Name:RENSSELAER OPERATING CO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGHESE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, GNP, LNHA
Authorized Official - Phone:518-374-2212
Mailing Address - Street 1:284 TROY RD
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-9474
Mailing Address - Country:US
Mailing Address - Phone:518-286-1621
Mailing Address - Fax:518-286-1691
Practice Address - Street 1:284 TROY RD
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144-9474
Practice Address - Country:US
Practice Address - Phone:518-286-1621
Practice Address - Fax:518-286-1691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4152302N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01073376Medicaid
NY01073376Medicaid