Healthcare Provider Details

I. General information

NPI: 1760476568
Provider Name (Legal Business Name): PENN YAN MANOR NURSING HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 LIBERTY ST
PENN YAN NY
14527-1086
US

IV. Provider business mailing address

655 LIBERTY ST
PENN YAN NY
14527-1086
US

V. Phone/Fax

Practice location:
  • Phone: 315-536-2311
  • Fax: 315-536-1033
Mailing address:
  • Phone: 315-536-2311
  • Fax: 315-924-2906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number6120300N
License Number StateNY

VIII. Authorized Official

Name: JESSICA FISH
Title or Position: FISCAL MANAGER
Credential:
Phone: 315-536-2311