Basic Information
| Provider Information | |||||||||
| NPI: | 1104059856 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARKSHORE HEALTH CARE LLC | ||||||||
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| OtherOrganizationName: | FOUR SEASONS NURSING & REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 ROCKAWAY PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112364001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189276300 | ||||||||
| FaxNumber: | 7182722166 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 ROCKAWAY PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112364001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189276300 | ||||||||
| FaxNumber: | 7182722166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2009 | ||||||||
| LastUpdateDate: | 08/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | FRIEDMAN | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7189276300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 7001385N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00843485 | 05 | NY | MEDICAID |