Provider Demographics
NPI:1023162211
Name:LORETTO UTICA RESIDENTIAL HEALTH CARE FACILITY
Entity type:Organization
Organization Name:LORETTO UTICA RESIDENTIAL HEALTH CARE FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SYNOKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:315-732-0100
Mailing Address - Street 1:1445 KEMBLE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4441
Mailing Address - Country:US
Mailing Address - Phone:315-732-0100
Mailing Address - Fax:315-733-5718
Practice Address - Street 1:1445 KEMBLE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4441
Practice Address - Country:US
Practice Address - Phone:315-732-0100
Practice Address - Fax:315-733-5718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03A1629314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01640904Medicaid
NY01640913Medicaid
NY01640913Medicaid