Healthcare Provider Details

I. General information

NPI: 1467814632
Provider Name (Legal Business Name): 111 ENSMINGER ROAD OPERATING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ENSMINGER RD
TONAWANDA NY
14150-6719
US

IV. Provider business mailing address

111 ENSMINGER RD
TONAWANDA NY
14150-6719
US

V. Phone/Fax

Practice location:
  • Phone: 716-871-1814
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: ROBERT HEYERT
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 917-690-5914