Provider Demographics
NPI:1457332892
Name:NORTHERN MANOR MULTICARE CENTER INC
Entity Type:Organization
Organization Name:NORTHERN MANOR MULTICARE CENTER INC
Other - Org Name:NORTHERN MANOR GERIATRIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BARDACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-623-3904
Mailing Address - Street 1:199 N MIDDLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-1317
Mailing Address - Country:US
Mailing Address - Phone:845-623-3904
Mailing Address - Fax:845-623-8908
Practice Address - Street 1:199 N MIDDLETOWN RD
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-1317
Practice Address - Country:US
Practice Address - Phone:845-623-3904
Practice Address - Fax:845-623-8908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4350304N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00309568Medicaid
NY00309568Medicaid
1192890001Medicare NSC
NY335046Medicare Oscar/Certification