Provider Demographics
NPI:1285615682
Name:SUSQUEHANNA NURSING & REHABILITATION CENTER, LLC
Entity type:Organization
Organization Name:SUSQUEHANNA NURSING & REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-829-1554
Mailing Address - Street 1:282 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2727
Mailing Address - Country:US
Mailing Address - Phone:607-729-9206
Mailing Address - Fax:607-797-3229
Practice Address - Street 1:282 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2727
Practice Address - Country:US
Practice Address - Phone:607-729-9206
Practice Address - Fax:607-797-3229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
NY0303307N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00311037Medicaid
NY00811629Medicaid
NY0303307NOtherOPERATING CERTIFICATE
NY335393Medicare ID - Type Unspecified