Provider Demographics
NPI:1316066566
Name:DAVID J WEGMAN
Entity type:Organization
Organization Name:DAVID J WEGMAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OUTSOURCED CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-392-7171
Mailing Address - Street 1:231 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-1333
Mailing Address - Country:US
Mailing Address - Phone:585-392-7171
Mailing Address - Fax:585-392-3631
Practice Address - Street 1:231 EAST AVE
Practice Address - Street 2:
Practice Address - City:HILTON
Practice Address - State:NY
Practice Address - Zip Code:14468-1333
Practice Address - Country:US
Practice Address - Phone:585-392-7171
Practice Address - Fax:585-392-3631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
NY370F208310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01614539Medicaid