Provider Demographics
NPI:1104063270
Name:SURFSIDE MANOR HFA LHCSA
Entity type:Organization
Organization Name:SURFSIDE MANOR HFA LHCSA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN-PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:718-713-0004
Mailing Address - Street 1:214 BEACH 96TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1338
Mailing Address - Country:US
Mailing Address - Phone:718-713-0004
Mailing Address - Fax:718-713-0008
Practice Address - Street 1:214 BEACH 96TH ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1338
Practice Address - Country:US
Practice Address - Phone:718-713-0004
Practice Address - Fax:718-713-0008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1150L001251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1150L001OtherLICENSE NUMBER