Provider Demographics
NPI:1700848447
Name:OUR LADY OF CONSOLATION GERIATRIC CARE CENTER
Entity Type:Organization
Organization Name:OUR LADY OF CONSOLATION GERIATRIC CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-465-6442
Mailing Address - Street 1:111 BEACH DR
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4929
Mailing Address - Country:US
Mailing Address - Phone:631-587-1600
Mailing Address - Fax:631-587-3263
Practice Address - Street 1:111 BEACH DR
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4929
Practice Address - Country:US
Practice Address - Phone:631-587-1600
Practice Address - Fax:631-587-3263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5154901L251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00830355Medicaid
NY5154901LOtherOPERATING CERTIFICATE #
NY337197Medicare ID - Type UnspecifiedLTHHC MEDICARE
NY337197Medicare PIN
NY00830355Medicaid
NY5154901LOtherOPERATING CERTIFICATE #