Provider Demographics
NPI:1194894022
Name:MOHAWK VALLEY NURSING HOME
Entity type:Organization
Organization Name:MOHAWK VALLEY NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-895-4050
Mailing Address - Street 1:99 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-1527
Mailing Address - Country:US
Mailing Address - Phone:315-895-4050
Mailing Address - Fax:315-895-7197
Practice Address - Street 1:99 6TH AVE
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-1527
Practice Address - Country:US
Practice Address - Phone:315-895-4050
Practice Address - Fax:315-895-7197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00473941Medicaid
NY01167977Medicaid
NY00473941Medicaid