Provider Demographics
NPI:1467534974
Name:ST. LUKE RESIDENTIAL HEALTH CARE FACILITY, INC.
Entity Type:Organization
Organization Name:ST. LUKE RESIDENTIAL HEALTH CARE FACILITY, INC.
Other - Org Name:ST. LUKE ADHC
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-342-3166
Mailing Address - Street 1:299 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-6400
Mailing Address - Country:US
Mailing Address - Phone:315-342-3166
Mailing Address - Fax:315-343-6531
Practice Address - Street 1:299 E RIVER RD
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-6400
Practice Address - Country:US
Practice Address - Phone:315-342-3166
Practice Address - Fax:315-343-6531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01407538Medicaid