Provider Demographics
NPI:1487057972
Name:MARY AGNES MANOR
Entity type:Organization
Organization Name:MARY AGNES MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZYSKIND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-791-4211
Mailing Address - Street 1:307 PORTER AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-1031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 PORTER AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201-1031
Practice Address - Country:US
Practice Address - Phone:716-881-0565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1753L0013104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness