Basic Information
| Provider Information | |||||||||
| NPI: | 1528003902 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRANVILLE NURSING AND REHABILITATION CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE ORCHARD NURSING AND REHABILITATION CENTRE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10421 STATE ROUTE 40 | ||||||||
| Address2: | |||||||||
| City: | GRANVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128325713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186422346 | ||||||||
| FaxNumber: | 5186423870 | ||||||||
| Practice Location | |||||||||
| Address1: | 10421 STATE ROUTE 40 | ||||||||
| Address2: | |||||||||
| City: | GRANVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128325713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186422346 | ||||||||
| FaxNumber: | 5186423870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 11/22/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTONE | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5183469640 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DMN MANAGEMENT SERVICES, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5725303N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 956381 | 01 | NY | MVP | OTHER | 000400690009 | 01 | NY | BLUE SHIELD | OTHER | 302056 | 01 | NY | WELLCARE | OTHER | 007991 | 01 | NY | EMPIRE BC | OTHER | 01167931 | 05 | NY | MEDICAID | 10054923 | 01 | NY | CDPHP | OTHER |