Basic Information
| Provider Information | |||||||||
| NPI: | 1629225867 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NESCONSET ACQUISITION LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ISLIP ADHS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 100 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | NESCONSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117671749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313618800 | ||||||||
| FaxNumber: | 6313619528 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 CLAYTON ST | ||||||||
| Address2: | |||||||||
| City: | CENTRAL ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117223021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312340550 | ||||||||
| FaxNumber: | 6312340635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2008 | ||||||||
| LastUpdateDate: | 04/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEPPENHEIMER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6313618800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NESCONSET ACQUISITION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5157507N | NY | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 311Z00000X | 5157315N | NY | Y | Nursing & Custodial Care Facilities | Custodial Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 00848751 | 05 | NY | MEDICAID |