Basic Information
| Provider Information | |||||||||
| NPI: | 1346376373 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROSPECT PARK NURSING HOME | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROSPECT PARK CARE CENTER, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1455 CONEY ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112304713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182529800 | ||||||||
| FaxNumber: | 7189516742 | ||||||||
| Practice Location | |||||||||
| Address1: | 1455 CONEY ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112304713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182529800 | ||||||||
| FaxNumber: | 7189516742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FELDMAN | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASST. ADM. | ||||||||
| AuthorizedOfficialTelephone: | 7182529800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 7001338N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00312547 | 05 | NY | MEDICAID |