1124563994 NPI number — PEARL VALLEY REHABILITATION AND NURSING AT LAKE PARK, LLC

Table of content: (NPI 1114967965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124563994 NPI number — PEARL VALLEY REHABILITATION AND NURSING AT LAKE PARK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEARL VALLEY REHABILITATION AND NURSING AT LAKE PARK, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124563994
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1576 E 27TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11229-1710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1304 S MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PARK
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51347-1060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-832-3691
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DORFMAN
Authorized Official First Name:
YAAKOV
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER (GREATER THAN 5 PERCENT)
Authorized Official Telephone Number:
551-206-2647

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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