Provider Demographics
NPI:1205041522
Name:MOHAWK MANOR REST HOME, INC
Entity Type:Organization
Organization Name:MOHAWK MANOR REST HOME, INC
Other - Org Name:MOHAWK MANOR REST HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BISSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-625-6860
Mailing Address - Street 1:45 WATER ST
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:01370-1126
Mailing Address - Country:US
Mailing Address - Phone:413-625-6860
Mailing Address - Fax:413-625-6136
Practice Address - Street 1:45 WATER ST
Practice Address - Street 2:
Practice Address - City:SHELBURNE FALLS
Practice Address - State:MA
Practice Address - Zip Code:01370-1126
Practice Address - Country:US
Practice Address - Phone:413-625-6860
Practice Address - Fax:413-625-6136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1290311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5500907Medicaid