1255334082 NPI number — PINEGROVE MANOR II, LLC

Table of content: (NPI 1255334082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255334082 NPI number — PINEGROVE MANOR II, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINEGROVE MANOR II, 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:
GRACE PLAZA NURSING AND REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
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:
1255334082
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 SAINT PAULS PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREAT NECK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11021-2636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-466-3001
Provider Business Mailing Address Fax Number:
516-466-7624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 SAINT PAULS PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREAT NECK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11021-2636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-466-3001
Provider Business Practice Location Address Fax Number:
516-466-7624
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SODANO
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
516-466-3001

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2913301N , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 335483 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 007385 . This is a "BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00309119 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: A418337 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".




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