Provider Demographics
NPI:1760419915
Name:BURGUNDI MANOR OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:BURGUNDI MANOR OPERATING COMPANY, LLC
Other - Org Name:DANRIDGE'S BURGUNDI MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:BERGSTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-825-6622
Mailing Address - Street 1:31 MARANATHA CT
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-4970
Mailing Address - Country:US
Mailing Address - Phone:330-746-5157
Mailing Address - Fax:330-746-2508
Practice Address - Street 1:31 MARANTHA DRIVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-4505
Practice Address - Country:US
Practice Address - Phone:330-746-5157
Practice Address - Fax:330-746-2508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2232NH314000000X
OH2232N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0364950001OtherDEMERC
OH3102127Medicaid
OH2089396Medicaid
OH0364950001OtherDEMERC