Provider Demographics
NPI:1710050695
Name:MARTIN LUTHER NURSING HOME, INC.
Entity Type:Organization
Organization Name:MARTIN LUTHER NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DURR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-235-7180
Mailing Address - Street 1:110 UTICA RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-1548
Mailing Address - Country:US
Mailing Address - Phone:315-853-5515
Mailing Address - Fax:
Practice Address - Street 1:110 UTICA RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1548
Practice Address - Country:US
Practice Address - Phone:315-853-5515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02329739343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00474373Medicaid
NY335186Medicare ID - Type Unspecified