Provider Demographics
NPI:1447286174
Name:ST JOHNLAND NURSING CENTER
Entity type:Organization
Organization Name:ST JOHNLAND NURSING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:MARY JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-269-5800
Mailing Address - Street 1:395 SUNKEN MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:395 SUNKEN MEADOW RD
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-1000
Practice Address - Country:US
Practice Address - Phone:631-269-5800
Practice Address - Fax:631-269-5876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5157311N333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00309393Medicaid
3349328OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY00309393Medicaid