Healthcare Provider Details

I. General information

NPI: 1124013115
Provider Name (Legal Business Name): PLAZA NURSING HOME COMPANY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 S CROUSE AVE
SYRACUSE NY
13210-1711
US

IV. Provider business mailing address

614 S CROUSE AVE
SYRACUSE NY
13210-1711
US

V. Phone/Fax

Practice location:
  • Phone: 315-474-4431
  • Fax: 315-474-7177
Mailing address:
  • Phone: 315-474-4431
  • Fax: 315-474-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3301323N
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00356405
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: MRS. JOYCE G. WARRINER
Title or Position: CEO/ADMINISTRATOR
Credential: CEO
Phone: 315-474-4431