Provider Demographics
NPI:1548399488
Name:ST.DOMINIC'S HOME
Entity Type:Organization
Organization Name:ST.DOMINIC'S HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KYDON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:845-359-3400
Mailing Address - Street 1:500 WESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:BLAUVELT
Mailing Address - State:NY
Mailing Address - Zip Code:10913-2000
Mailing Address - Country:US
Mailing Address - Phone:845-359-3400
Mailing Address - Fax:845-359-4253
Practice Address - Street 1:500 WESTERN HWY
Practice Address - Street 2:
Practice Address - City:BLAUVELT
Practice Address - State:NY
Practice Address - Zip Code:10913-2000
Practice Address - Country:US
Practice Address - Phone:845-359-3400
Practice Address - Fax:845-359-4253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY07159457315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02840751Medicaid