Basic Information
| Provider Information | |||||||||
| NPI: | 1154584886 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK HOUSE CARE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 BEACH 115 STREET | ||||||||
| Address2: | |||||||||
| City: | ROCKAWAY PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184746400 | ||||||||
| FaxNumber: | 7184749669 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 BEACH 115 STREET | ||||||||
| Address2: | |||||||||
| City: | ROCKAWAY BEACH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184746400 | ||||||||
| FaxNumber: | 7184743663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 07/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | MELNICKE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7184746400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 00312487 | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.