Basic Information
| Provider Information | |||||||||
| NPI: | 1932146933 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARBOR PARK HEALTH CARE CENTER, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE WATERS OF EDEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 300 GLEED AVE | ||||||||
| Address2: | CO THE PARK ASSOCIATES, INC. | ||||||||
| City: | EAST AURORA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140522980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166522820 | ||||||||
| FaxNumber: | 7166552320 | ||||||||
| Practice Location | |||||||||
| Address1: | 2806 GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | EDEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140571205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169923987 | ||||||||
| FaxNumber: | 7169922281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7168051474 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1461301N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00011438901 | 01 | NY | UNIVERA | OTHER | 000000225000 | 01 | NY | BLUE CROSS & BLUE SHIELD | OTHER | 01058777 | 05 | NY | MEDICAID | 1V | 01 | NY | INDEPENDENT HEALTH | OTHER |