Woodhaven Adult Home, LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

700-F-905 Issued in NY

Legal business name

WOODHAVEN ADULT HOME, LLC

Practice address

1350 Route 112
Port Jefferson Station, NY 11776-3078

Phone

(631) 473-7100

Fax

(631) 473-7118

NPI assigned

Apr 3, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Kenneth E Gaul

Title

Sole Member

Phone

(631) 473-7100

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175558400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1609998681",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1360 ROUTE 112",
            "city": "PORT JEFFERSON STATION",
            "state": "NY",
            "postal_code": "117763078",
            "telephone_number": "631-473-7100",
            "fax_number": "631-473-7118"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1350 ROUTE 112",
            "city": "PORT JEFFERSON STATION",
            "state": "NY",
            "postal_code": "117763078",
            "telephone_number": "631-473-7100",
            "fax_number": "631-473-7118"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WOODHAVEN ADULT HOME, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-03",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "GAUL",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "SOLE MEMBER",
        "authorized_official_telephone_number": "631-473-7100",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "NY",
            "license": "700-F-905",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02362614",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Assisted Living Facility in Port Jefferson Station, NY
• Providers in Port Jefferson Station, NY by specialty
• Assisted Living Facility in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.