Provider Demographics
NPI:1033106463
Name:RIVERHEAD CARE CENTER LLC
Entity Type:Organization
Organization Name:RIVERHEAD CARE CENTER LLC
Other - Org Name:RIVERHEAD NURSING HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGELS
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:631-727-4400
Mailing Address - Street 1:1146 WOODCREST AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2016
Mailing Address - Country:US
Mailing Address - Phone:631-727-4400
Mailing Address - Fax:631-727-7223
Practice Address - Street 1:1146 WOODCREST AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2016
Practice Address - Country:US
Practice Address - Phone:631-727-4400
Practice Address - Fax:631-727-7223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5155301N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0941OtherPFI NUMBER
NY5155301NMedicaid
NY0941OtherPFI NUMBER