Healthcare Provider Details

I. General information

NPI: 1972669364
Provider Name (Legal Business Name): MONTGOMERY NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ALBANY POST RD
MONTGOMERY NY
12549-2132
US

IV. Provider business mailing address

2817 ALBANY POST RD
MONTGOMERY NY
12549-2132
US

V. Phone/Fax

Practice location:
  • Phone: 845-457-3155
  • Fax:
Mailing address:
  • Phone: 845-457-3155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3560301N
License Number StateNY

VIII. Authorized Official

Name: DR. JEREMY R MACK
Title or Position: PARTNER
Credential:
Phone: 845-457-3155