Provider Demographics
NPI:1568891810
Name:MEMORY GARDEN AT TANGLEWOOD MANOR, INC
Entity Type:Organization
Organization Name:MEMORY GARDEN AT TANGLEWOOD MANOR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:INGERSOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-483-2876
Mailing Address - Street 1:560 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-2749
Mailing Address - Country:US
Mailing Address - Phone:716-483-2876
Mailing Address - Fax:
Practice Address - Street 1:560 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2749
Practice Address - Country:US
Practice Address - Phone:716-483-2876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060F040311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03369835Medicaid