Provider Demographics
NPI:1336518539
Name:PLEASANTVILLE OPERATING LLC
Entity type:Organization
Organization Name:PLEASANTVILLE OPERATING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES-EDOUARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-360-8083
Mailing Address - Street 1:13742 71ST AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1939
Mailing Address - Country:US
Mailing Address - Phone:718-360-8083
Mailing Address - Fax:
Practice Address - Street 1:1100 CLEMATIS AVE
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232-3302
Practice Address - Country:US
Practice Address - Phone:718-360-8083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLEASANTVILLE VENTURES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ060106314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4462203Medicaid
NJ4462203Medicaid