Basic Information
| Provider Information | |||||||||
| NPI: | 1477554723 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARKSHORE HEALTHCARE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FOUR SEASONS NURSING & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1555 ROCKAWAY PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112364001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189276300 | ||||||||
| FaxNumber: | 7182722166 | ||||||||
| Practice Location | |||||||||
| Address1: | 1535 ROCKAWAY PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112364001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189276300 | ||||||||
| FaxNumber: | 7182722166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 01/30/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FRIEDMAN | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7189276300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 7001916L | NY | N | Agencies | Home Health | 251E00000X | 7001641 | NY | N | Agencies | Home Health | 314000000X | 7001385N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 7001361N | 01 | NY | STATE OPERATING CERTF. # | OTHER | 02995779 | 05 | NY | MEDICAID | 7001641 | 01 | NY | STATE OPER CERT# CHHA | OTHER | 7001385N | 01 | STATE OPERATING CERT # | OTHER | 00843485 | 05 | NY | MEDICAID | 3227 | 01 | NY | PFI | OTHER | 7001916L | 01 | STATE OPER CERT# LTHHCP | OTHER |