Provider Demographics
NPI:1780825851
Name:LONG ISLAND STATE VETERANS HOME SUNY AT STONY BROOK
Entity Type:Organization
Organization Name:LONG ISLAND STATE VETERANS HOME SUNY AT STONY BROOK
Other - Org Name:LONG ISLAND STATE VETERANS HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:SGANGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-444-8500
Mailing Address - Street 1:100 PATRIOTS RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3318
Mailing Address - Country:US
Mailing Address - Phone:631-444-8500
Mailing Address - Fax:631-444-8575
Practice Address - Street 1:100 PATRIOTS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3318
Practice Address - Country:US
Practice Address - Phone:631-444-8500
Practice Address - Fax:631-444-8575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5151310N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility