Provider Demographics
NPI:1659314193
Name:CLOVE LAKES REHABILITATION AND OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:CLOVE LAKES REHABILITATION AND OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANCIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-289-7034
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:718-289-7890
Mailing Address - Fax:718-761-8701
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:718-289-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-13
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01876104Medicaid
NY01876104Medicaid