Healthcare Provider Details

I. General information

NPI: 1760419915
Provider Name (Legal Business Name): BURGUNDI MANOR OPERATING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 MARANTHA DRIVE
YOUNGSTOWN OH
44505-4505
US

IV. Provider business mailing address

31 MARANATHA CT
YOUNGSTOWN OH
44505-4970
US

V. Phone/Fax

Practice location:
  • Phone: 330-746-5157
  • Fax: 330-746-2508
Mailing address:
  • Phone: 330-746-5157
  • Fax: 330-746-2508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2232NH
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2232N
License Number StateOH

VIII. Authorized Official

Name: PAUL B. BERGSTEN
Title or Position: CEO
Credential:
Phone: 937-825-6622