1356395909 NPI number — HERITAGE HOUSE NURSING CENTER, INC

Table of content: (NPI 1356395909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356395909 NPI number — HERITAGE HOUSE NURSING CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE HOUSE NURSING CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EDDY HERITAGE HOUSE NURSING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356395909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 WEST COLUMBIA STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COHOES
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12047-2217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-274-4125
Provider Business Mailing Address Fax Number:
518-274-4337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2920 TIBBITS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12180-7077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-274-4125
Provider Business Practice Location Address Fax Number:
518-274-4337
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHEELER
Authorized Official First Name:
JUANITA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
518-238-4045

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  4102311N , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7419009 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 009611 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 012299 . This is a "BLUE CROSS FEDERAL" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10023491 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000400107001 . This is a "BLUE SHIELD OF NE NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01365177 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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