Provider Demographics
NPI:1033110770
Name:PECONIC LANDING AT SOUTHOLD INC
Entity Type:Organization
Organization Name:PECONIC LANDING AT SOUTHOLD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-477-3800
Mailing Address - Street 1:1500 BRECKNOCK RD
Mailing Address - Street 2:
Mailing Address - City:GREENPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11944-3117
Mailing Address - Country:US
Mailing Address - Phone:631-477-3800
Mailing Address - Fax:631-477-3900
Practice Address - Street 1:1500 BRECKNOCK RD
Practice Address - Street 2:
Practice Address - City:GREENPORT
Practice Address - State:NY
Practice Address - Zip Code:11944-3117
Practice Address - Country:US
Practice Address - Phone:631-477-3800
Practice Address - Fax:631-477-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02410795Medicaid
NY335842Medicare ID - Type Unspecified