Provider Demographics
NPI:1730288549
Name:FAXTON-SUNSET ST. LUKE'S HEALTH CARE CENTER INC
Entity Type:Organization
Organization Name:FAXTON-SUNSET ST. LUKE'S HEALTH CARE CENTER INC
Other - Org Name:HERITAGE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-797-7392
Mailing Address - Street 1:1657 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5415
Mailing Address - Country:US
Mailing Address - Phone:315-797-7392
Mailing Address - Fax:315-797-8267
Practice Address - Street 1:1657 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5415
Practice Address - Country:US
Practice Address - Phone:315-797-7392
Practice Address - Fax:315-797-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3202314N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00474355Medicaid
NY00474355Medicaid