MEDICARE: EAST SIDE NURSING HOME, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	6027303N	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750389789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST SIDE NURSING HOME, INC.

Provider Business Mailing Address
First Line	:	62 PROSPECT ST
Second Line	:
City	:	WARSAW
State	:	NY
Zip	:	14569-1533
Country	:	US
Telephone Number	:	585-786-8151
Fax Number	:	585-786-8390

Provider Business Practice Location Address
First Line	:	62 PROSPECT ST
Second Line	:
City	:	WARSAW
State	:	NY
Zip	:	14569-1533
Country	:	US
Telephone Number	:	585-786-8151
Fax Number	:	585-786-8390

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. HAROLD P. COLLER
Credential	:
Telephone Number	:	585-786-8151

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	08/22/2020

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