Provider Demographics
NPI:1750389789
Name:EAST SIDE NURSING HOME, INC.
Entity type:Organization
Organization Name:EAST SIDE NURSING HOME, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:P
Authorized Official - Last Name:COLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-786-8151
Mailing Address - Street 1:62 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-1533
Mailing Address - Country:US
Mailing Address - Phone:585-786-8151
Mailing Address - Fax:585-786-8390
Practice Address - Street 1:62 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-1533
Practice Address - Country:US
Practice Address - Phone:585-786-8151
Practice Address - Fax:585-786-8390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6027303N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00356083Medicaid
NY00356083Medicaid