Provider Demographics
NPI:1992854103
Name:CLINTON COUNTY
Entity Type:Organization
Organization Name:CLINTON COUNTY
Other - Org Name:CLINTON COUNTY NURSING HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:COMPTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PEDULLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-563-0950
Mailing Address - Street 1:16 FLYNN AVENUE
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-3797
Mailing Address - Country:US
Mailing Address - Phone:518-563-0950
Mailing Address - Fax:518-563-1060
Practice Address - Street 1:16 FLYNN AVENUE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-3797
Practice Address - Country:US
Practice Address - Phone:518-563-0950
Practice Address - Fax:518-563-1060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0952300N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00583624Medicaid
NY00583624Medicaid