Provider Demographics
NPI:1063419356
Name:MARIA REGINA RESIDENCE, INC.
Entity type:Organization
Organization Name:MARIA REGINA RESIDENCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ILANA
Authorized Official - Middle Name:
Authorized Official - Last Name:AVINARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-447-1542
Mailing Address - Street 1:1725 BRENTWOOD RD
Mailing Address - Street 2:BLDG 1
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-5543
Mailing Address - Country:US
Mailing Address - Phone:845-447-1542
Mailing Address - Fax:845-447-1544
Practice Address - Street 1:1725 BRENTWOOD RD
Practice Address - Street 2:BLDG 1
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-5543
Practice Address - Country:US
Practice Address - Phone:631-299-3000
Practice Address - Fax:631-299-3274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5154321N314000000X
261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02277085Medicaid
NY02496748Medicaid
NY02277085Medicaid