Provider Demographics
NPI:1053390534
Name:ST VINCENT DE PAUL RESIDENCE
Entity type:Organization
Organization Name:ST VINCENT DE PAUL RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SRVP CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANNMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COVONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-633-4702
Mailing Address - Street 1:900 INTERVALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-4240
Mailing Address - Country:US
Mailing Address - Phone:646-633-4774
Mailing Address - Fax:
Practice Address - Street 1:900 INTERVALE AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459
Practice Address - Country:US
Practice Address - Phone:917-645-9201
Practice Address - Fax:718-589-7010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7000366N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01367115Medicaid
NY01446244Medicaid
NY01367115Medicaid