Provider Demographics
NPI:1457435877
Name:LACONIA NURSING HOME INC.
Entity Type:Organization
Organization Name:LACONIA NURSING HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LUBA
Authorized Official - Middle Name:
Authorized Official - Last Name:SERVIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-654-5875
Mailing Address - Street 1:1050 E 230TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-4810
Mailing Address - Country:US
Mailing Address - Phone:718-654-5875
Mailing Address - Fax:718-405-5958
Practice Address - Street 1:1050 E 230TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-4810
Practice Address - Country:US
Practice Address - Phone:718-654-5875
Practice Address - Fax:718-701-5684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7000370N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00311468Medicaid
NY335388Medicare ID - Type Unspecified