Provider Demographics
NPI:1649285479
Name:SPRAIN BROOK MANOR NURSING HOME
Entity type:Organization
Organization Name:SPRAIN BROOK MANOR NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-472-3200
Mailing Address - Street 1:77 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-3140
Mailing Address - Country:US
Mailing Address - Phone:914-472-3200
Mailing Address - Fax:914-472-5443
Practice Address - Street 1:77 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-3140
Practice Address - Country:US
Practice Address - Phone:914-472-3200
Practice Address - Fax:914-472-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5910300N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5910300NOtherOPERATING CERTIFICATE NO.
NY1114OtherPFI
NY00308338Medicaid
NY335320Medicare ID - Type Unspecified