Provider Demographics
NPI:1760476568
Name:PENN YAN MANOR NURSING HOME, INC.
Entity Type:Organization
Organization Name:PENN YAN MANOR NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FISCAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-536-2311
Mailing Address - Street 1:655 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1048
Mailing Address - Country:US
Mailing Address - Phone:315-536-2311
Mailing Address - Fax:315-536-1033
Practice Address - Street 1:655 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1048
Practice Address - Country:US
Practice Address - Phone:315-536-2311
Practice Address - Fax:315-536-1033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6120300N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355711Medicaid
NY6120300NOtherOPERATING CERTIFICATE
NY1162OtherPFI
NY00355711Medicaid