Organization
WOODHAVEN ADULT HOME, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KENNETH E GAUL (SOLE MEMBER)
(631) 473-7100
Entity
Organization
Contact information
Practice address
1350 ROUTE 112, PORT JEFFERSON STATION, NY 11776-3078
(631) 473-7100
(631) 473-7118
Mailing address
1360 ROUTE 112, PORT JEFFERSON STATION, NY 11776-3078
(631) 473-7100
(631) 473-7118
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
700-F-905
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02362614
—
NY
Enumeration date
04/03/2007
Last updated
08/22/2020
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