Provider Demographics
NPI:1710993944
Name:TRUSTEES OF THE EASTERN STAR HALL AND HOME OF THE STATE OF NEW YORK
Entity Type:Organization
Organization Name:TRUSTEES OF THE EASTERN STAR HALL AND HOME OF THE STATE OF NEW YORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRENCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-736-9311
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:8290 STATE ROUTE 69
Mailing Address - City:ORISKANY
Mailing Address - State:NY
Mailing Address - Zip Code:13424-0959
Mailing Address - Country:US
Mailing Address - Phone:315-736-9311
Mailing Address - Fax:315-736-3047
Practice Address - Street 1:8290 STATE ROUTE 69
Practice Address - Street 2:
Practice Address - City:ORISKANY
Practice Address - State:NY
Practice Address - Zip Code:13424-0959
Practice Address - Country:US
Practice Address - Phone:315-736-9311
Practice Address - Fax:315-736-3047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3239300N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00310494Medicaid
NY81016AMedicare PIN
NY335497Medicare PIN