Basic Information
| Provider Information | |||||||||
| NPI: | 1184611758 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINE VALLEY CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PINE VALLEY CENTER FOR REHABILITATION AND NURSING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 661 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRING VALLEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109772319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454265600 | ||||||||
| FaxNumber: | 8453522704 | ||||||||
| Practice Location | |||||||||
| Address1: | 661 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRING VALLEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109772319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454265600 | ||||||||
| FaxNumber: | 8453522704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 07/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | TROPPER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8454265600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 207RG0300X | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00311082 | 05 | NY | MEDICAID |