Provider Demographics
NPI:1376667782
Name:LAKE SHORE NURSING HOME
Entity type:Organization
Organization Name:LAKE SHORE NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHREIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-951-7147
Mailing Address - Street 1:12644 SENECA RD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:NY
Mailing Address - Zip Code:14081-9714
Mailing Address - Country:US
Mailing Address - Phone:716-951-7060
Mailing Address - Fax:
Practice Address - Street 1:845 ROUTES 5 AND 20
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:NY
Practice Address - Zip Code:14081-9714
Practice Address - Country:US
Practice Address - Phone:716-951-7060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00475163Medicaid
NY00475163Medicaid