Provider Demographics
NPI:1588603948
Name:SULLIVAN PARK HEALTHCARE CENTER, INC
Entity Type:Organization
Organization Name:SULLIVAN PARK HEALTHCARE CENTER, INC
Other - Org Name:THE WATERS OF ENDICOTT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-805-1474
Mailing Address - Street 1:300 GLEED AVE
Mailing Address - Street 2:THE PARK ASSOCIATES, INC.
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-2980
Mailing Address - Country:US
Mailing Address - Phone:716-652-2820
Mailing Address - Fax:716-655-2320
Practice Address - Street 1:301 NANTUCKET DR
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-2735
Practice Address - Country:US
Practice Address - Phone:607-754-2705
Practice Address - Fax:607-754-2610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0302301N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00949817Medicaid
NY00949817Medicaid
NY335371Medicare Oscar/Certification
NYRB2192Medicare PIN