Provider Demographics
NPI:1912904541
Name:COUNTY OF SULLIVAN
Entity type:Organization
Organization Name:COUNTY OF SULLIVAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHENNOY
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:845-513-2129
Mailing Address - Street 1:PO BOX 671
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-0671
Mailing Address - Country:US
Mailing Address - Phone:845-292-8640
Mailing Address - Fax:845-513-2177
Practice Address - Street 1:256 SUNSET LAKE RD.
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-0671
Practice Address - Country:US
Practice Address - Phone:845-292-8640
Practice Address - Fax:845-513-2177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00309040Medicaid
NYW79271Medicare ID - Type UnspecifiedPROVIDER ID
NY335628Medicare ID - Type UnspecifiedPROVIDER ID