Provider Demographics
NPI:1821205584
Name:JEFFERSON REHABILITATION CENTER
Entity Type:Organization
Organization Name:JEFFERSON REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-788-2730
Mailing Address - Street 1:PO BOX 41
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-0041
Mailing Address - Country:US
Mailing Address - Phone:315-788-2730
Mailing Address - Fax:315-788-8557
Practice Address - Street 1:301 E GROVE ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:NY
Practice Address - Zip Code:13634-3147
Practice Address - Country:US
Practice Address - Phone:315-639-6333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7642450315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01214662Medicaid