Basic Information
| Provider Information | |||||||||
| NPI: | 1548253313 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUEENS BOULEVARD EXTENDED CARE FACILITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6111 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182050287 | ||||||||
| FaxNumber: | 7182051342 | ||||||||
| Practice Location | |||||||||
| Address1: | 6111 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182050287 | ||||||||
| FaxNumber: | 7182051342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COHEN | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7182050287 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 7003390N | NY | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 01626686 | 05 | NY | MEDICAID | 01710672 | 05 | NY | MEDICAID | 7003390N | 05 | NY | MEDICAID |