1245384189 NPI number — WELLS NURSING HOME, INC

Table of content: (NPI 1245384189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245384189 NPI number — WELLS NURSING HOME, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLS NURSING HOME, 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:
WELLS HOUSE PHYSICAL THERAPY
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:
1245384189
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:
201 W MADISON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12095-2806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-762-4548
Provider Business Mailing Address Fax Number:
518-736-1570

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 W MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12095-2806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-762-4548
Provider Business Practice Location Address Fax Number:
518-736-1570
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VANSLYKE
Authorized Official First Name:
NEAL
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
518-762-4546

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1702300N , 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: 0039494849 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007964 . This is a "EMPIRE BLUECROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: GRP490087001 . This is a "BLUESHIELD OF NENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1797 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 43015 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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