Provider Demographics
NPI:1831195270
Name:HERITAGE VILLAGE REHAB & SKILLED NURSING INC
Entity type:Organization
Organization Name:HERITAGE VILLAGE REHAB & SKILLED NURSING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-338-9766
Mailing Address - Street 1:4570 ROUTE 60
Mailing Address - Street 2:PO BOX 367
Mailing Address - City:GERRY
Mailing Address - State:NY
Mailing Address - Zip Code:14740-0367
Mailing Address - Country:US
Mailing Address - Phone:716-985-6811
Mailing Address - Fax:716-985-6607
Practice Address - Street 1:4570 ROUTE 60
Practice Address - Street 2:
Practice Address - City:GERRY
Practice Address - State:NY
Practice Address - Zip Code:14740-0367
Practice Address - Country:US
Practice Address - Phone:716-985-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343900000X
NY0662300N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00356327Medicaid
00000022001OtherBLUE CROSS BLUE SHIELD
0031396101OtherSENIOR CHOICE
71Y200338OtherINDEPENDENT HEALTH EVERCA
0031396101OtherSENIOR CHOICE
NY8014AAMedicare ID - Type UnspecifiedMEDICARE PART B