Provider Demographics
NPI:1740287770
Name:ST. JOHNSVILLE REHABILITATION AND NURSING CENTER INC
Entity type:Organization
Organization Name:ST. JOHNSVILLE REHABILITATION AND NURSING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DYGERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-568-5037
Mailing Address - Street 1:7 TIMMERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13452-1017
Mailing Address - Country:US
Mailing Address - Phone:518-568-5037
Mailing Address - Fax:518-568-5477
Practice Address - Street 1:7 TIMMERMAN AVE
Practice Address - Street 2:
Practice Address - City:ST JOHNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13452-1017
Practice Address - Country:US
Practice Address - Phone:518-568-5037
Practice Address - Fax:518-568-5477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2828300N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01131093Medicaid
NY01131093Medicaid