Provider Demographics
NPI:1043481831
Name:HERITAGE MANOR OF LOCKPORT
Entity type:Organization
Organization Name:HERITAGE MANOR OF LOCKPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:STICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-433-7626
Mailing Address - Street 1:41 LEXINGTON CT
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5365
Mailing Address - Country:US
Mailing Address - Phone:716-433-7626
Mailing Address - Fax:716-433-7769
Practice Address - Street 1:41 LEXINGTON CT
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5365
Practice Address - Country:US
Practice Address - Phone:716-433-7626
Practice Address - Fax:716-433-7769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY500-F-093311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home