Basic Information
| Provider Information | |||||||||
| NPI: | 1497152664 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINEOLA NURSING AND REHAB CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MINEOLA HEALTHCARE RESIDENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CLIFTON AVE STE 17 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087013342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143963462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 716 MIMOSA DR | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757732612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035695366 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2014 | ||||||||
| LastUpdateDate: | 01/23/2017 | ||||||||
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| AuthorizedOfficialLastName: | NEUMAN | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2143963462 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5037 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001026604 | 05 | TX | MEDICAID |