Provider Demographics
NPI:1528054657
Name:FAIRCHILD MANOR NURSING HOME LLC
Entity type:Organization
Organization Name:FAIRCHILD MANOR NURSING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:I
Authorized Official - Last Name:KORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-867-4853
Mailing Address - Street 1:POST OFFICE BOX 0730
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-0730
Mailing Address - Country:US
Mailing Address - Phone:716-867-4853
Mailing Address - Fax:716-633-3369
Practice Address - Street 1:765 FAIRCHILD PL
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1309
Practice Address - Country:US
Practice Address - Phone:716-634-7600
Practice Address - Fax:716-633-3369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3121302N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02099296Medicaid
NY02099296Medicaid