Basic Information
| Provider Information | |||||||||
| NPI: | 1972926681 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | QUEENS BOULEVARD EXTENDED CARE FACILITY MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6111 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182050287 | ||||||||
| FaxNumber: | 7188030694 | ||||||||
| Practice Location | |||||||||
| Address1: | 6111 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182050287 | ||||||||
| FaxNumber: | 7188030694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2014 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | MALONE | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7182050287 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | 314000000X | 700341N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 7003410N | 05 | NY | MEDICAID | 02996110 | 05 | NY | MEDICAID | 1710672 | 05 | NY | MEDICAID |