Provider Demographics
NPI:1063419612
Name:NEW SURFSIDE NURSING HOME LLC
Entity type:Organization
Organization Name:NEW SURFSIDE NURSING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-471-3400
Mailing Address - Street 1:2241 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2538
Mailing Address - Country:US
Mailing Address - Phone:718-471-3400
Mailing Address - Fax:718-471-2802
Practice Address - Street 1:2241 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2538
Practice Address - Country:US
Practice Address - Phone:718-471-3400
Practice Address - Fax:718-471-2802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7003373N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00309724Medicaid
NY335165Medicare ID - Type Unspecified
NY1168180001Medicare NSC