Provider Demographics
NPI:1417952417
Name:CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER, INC.
Entity Type:Organization
Organization Name:CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORRI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SCULLIN-SENK
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:718-289-7890
Mailing Address - Street 1:25 FANNING ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5307
Mailing Address - Country:US
Mailing Address - Phone:718-289-7900
Mailing Address - Fax:718-289-7028
Practice Address - Street 1:25 FANNING ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5307
Practice Address - Country:US
Practice Address - Phone:718-289-7900
Practice Address - Fax:718-289-7028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7004305N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00309884Medicaid
NY00309884Medicaid