Provider Demographics
NPI:1013125467
Name:RONALD R. JOHNSON
Entity Type:Organization
Organization Name:RONALD R. JOHNSON
Other - Org Name:UNDERWOOD MANOR LLHCSA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-595-8784
Mailing Address - Street 1:2063 ROUTE 83
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14062-9639
Mailing Address - Country:US
Mailing Address - Phone:716-965-2644
Mailing Address - Fax:716-965-4163
Practice Address - Street 1:4460 UNION HILL RD
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:NY
Practice Address - Zip Code:14743-9715
Practice Address - Country:US
Practice Address - Phone:716-557-2322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0671A003311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02731313Medicaid
NY0671A003OtherDOH LICENSE