Provider Demographics
NPI:1861781759
Name:SELF
Entity type:Organization
Organization Name:SELF
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREANA
Authorized Official - Middle Name:H
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:L
Authorized Official - Phone:585-734-2650
Mailing Address - Street 1:29 HEBERTON RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14622-2405
Mailing Address - Country:US
Mailing Address - Phone:585-734-2650
Mailing Address - Fax:
Practice Address - Street 1:29 HEBERTON RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14622-2405
Practice Address - Country:US
Practice Address - Phone:585-734-2650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27300164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty