Basic Information
| Provider Information | |||||||||
| NPI: | 1104041029 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW BROADVIEW MANOR HFA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 FATHER CAPODANNO BLVD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103054803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182738900 | ||||||||
| FaxNumber: | 7187202415 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 FATHER CAPODANNO BLVD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103054803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182738900 | ||||||||
| FaxNumber: | 7187202415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 05/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | MARCOVICI | ||||||||
| AuthorizedOfficialFirstName: | LUDOVIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7182738900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 610 F 062 | NY | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 02375253 | 05 | NY | MEDICAID |