Provider Demographics
NPI:1629172762
Name:ST JOSEPHS REHABILITATION CENTER, INC
Entity Type:Organization
Organization Name:ST JOSEPHS REHABILITATION CENTER, INC
Other - Org Name:ST JOSEPHS ADDICTION TREATMENT & RECOVERY CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-891-3950
Mailing Address - Street 1:159 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-2385
Mailing Address - Country:US
Mailing Address - Phone:518-891-3950
Mailing Address - Fax:518-891-6134
Practice Address - Street 1:159 GLENWOOD DR
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-2385
Practice Address - Country:US
Practice Address - Phone:518-891-3950
Practice Address - Fax:518-891-6134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00689758Medicaid