Provider Demographics
NPI:1720073539
Name:OUR LADY OF PEACE INC.
Entity type:Organization
Organization Name:OUR LADY OF PEACE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRONEFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-729-3500
Mailing Address - Street 1:5285 LEWISTON RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-1942
Mailing Address - Country:US
Mailing Address - Phone:716-298-2900
Mailing Address - Fax:716-298-2800
Practice Address - Street 1:5285 LEWISTON RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1942
Practice Address - Country:US
Practice Address - Phone:716-298-2900
Practice Address - Fax:716-298-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3121303N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02415507Medicaid
NY335843Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER