Provider Demographics
NPI:1225019029
Name:WELLSVILLE MANOR LLC
Entity Type:Organization
Organization Name:WELLSVILLE MANOR LLC
Other - Org Name:WELLSVILLE MANOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, FISCAL OVERSIGHT
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEWIRTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-588-8379
Mailing Address - Street 1:4192A BOLIVAR RD
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-9325
Mailing Address - Country:US
Mailing Address - Phone:585-593-4400
Mailing Address - Fax:585-593-4418
Practice Address - Street 1:4192A BOLIVAR RD
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-9325
Practice Address - Country:US
Practice Address - Phone:585-593-4400
Practice Address - Fax:585-593-4418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00752167Medicaid
NY00752167Medicaid