Provider Demographics
NPI:1811334758
Name:SELF
Entity type:Organization
Organization Name:SELF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:ELCIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-413-6210
Mailing Address - Street 1:4 SPRUCE RD
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-1019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 SPRUCE RD
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-1019
Practice Address - Country:US
Practice Address - Phone:631-413-6210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SELF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-02
Last Update Date:2013-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102980029314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility