Basic Information
| Provider Information | |||||||||
| NPI: | 1497810675 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT LORETTO NURSING HOME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 302 SWART HILL RD | ||||||||
| Address2: | |||||||||
| City: | AMSTERDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120107081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188426790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 302 SWART HILL RD | ||||||||
| Address2: | |||||||||
| City: | AMSTERDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120107081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188426790 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHAMBERLIN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5188426790 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2850300N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2850300N | 05 | NY | MEDICAID |