Basic Information
| Provider Information | |||||||||
| NPI: | 1679797625 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIELDSTON LODGE CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 666 KAPPOCK ST | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104637704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175491203 | ||||||||
| FaxNumber: | 7188843792 | ||||||||
| Practice Location | |||||||||
| Address1: | 666 KAPPOCK ST | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104637704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175491203 | ||||||||
| FaxNumber: | 7188843792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 06/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | GEWIRTZ | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER, FISCAL OVERSIGHT | ||||||||
| AuthorizedOfficialTelephone: | 9145888379 | ||||||||
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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 | 314000000X | 7000385N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00310605 | 05 | NY | MEDICAID |