Provider Demographics
NPI:1760883383
Name:CENTRAL NEW YORK ADULT HOMES INC
Entity Type:Organization
Organization Name:CENTRAL NEW YORK ADULT HOMES INC
Other - Org Name:EVERGREEN HEIGHTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-834-6142
Mailing Address - Street 1:8939 OAKLAND ST
Mailing Address - Street 2:
Mailing Address - City:WEEDSPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13166-9417
Mailing Address - Country:US
Mailing Address - Phone:315-834-6142
Mailing Address - Fax:315-834-8960
Practice Address - Street 1:8939 OAKLAND ST
Practice Address - Street 2:
Practice Address - City:WEEDSPORT
Practice Address - State:NY
Practice Address - Zip Code:13166-9417
Practice Address - Country:US
Practice Address - Phone:315-834-6142
Practice Address - Fax:315-834-8960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050-E-010310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAF0158BOtherFACILITY IDENTIFICATION NUMBER
NY050-E-010OtherNEW YORK STATE DEPARTMENT OF HEALTH OPERATING CERTIFICATE