Provider Demographics
NPI:1740624709
Name:LORETTO INDEPENDENT LIVING SERVICES INC.
Entity type:Organization
Organization Name:LORETTO INDEPENDENT LIVING SERVICES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, PACE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ABULENCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-415-4449
Mailing Address - Street 1:100 MALTA LN
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-2375
Mailing Address - Country:US
Mailing Address - Phone:315-452-5800
Mailing Address - Fax:
Practice Address - Street 1:100 MALTA LN
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-2375
Practice Address - Country:US
Practice Address - Phone:315-452-5800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01519162Medicaid