Healthcare Provider Details

I. General information

NPI: 1194894022
Provider Name (Legal Business Name): MOHAWK VALLEY NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 6TH AVE
ILION NY
13357-1527
US

IV. Provider business mailing address

99 6TH AVE
ILION NY
13357-1527
US

V. Phone/Fax

Practice location:
  • Phone: 315-895-4050
  • Fax: 315-895-7197
Mailing address:
  • Phone: 315-895-4050
  • Fax: 315-895-7197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RALPH P REID
Title or Position: CEO
Credential:
Phone: 315-895-4050