Provider Demographics
NPI:1538771597
Name:ADIRONDACK MANOR HOME FOR ADULTS
Entity type:Organization
Organization Name:ADIRONDACK MANOR HOME FOR ADULTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROJECT MANAGER/EXECUTIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAJALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-988-4535
Mailing Address - Street 1:2357 60TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-2689
Mailing Address - Country:US
Mailing Address - Phone:718-840-3355
Mailing Address - Fax:516-244-9105
Practice Address - Street 1:653 BAY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1446
Practice Address - Country:US
Practice Address - Phone:718-840-3355
Practice Address - Fax:518-244-9105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-20
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251E00000XAgenciesHome Health
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0623L001OtherLHCSA LICENSE NO.