Provider Demographics
NPI:1043392657
Name:HILLSIDE MANOR REHABILITATION AND EXTENDED CARE CENTER, LLC
Entity Type:Organization
Organization Name:HILLSIDE MANOR REHABILITATION AND EXTENDED CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:WISSMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-291-8200
Mailing Address - Street 1:18215 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4853
Mailing Address - Country:US
Mailing Address - Phone:718-291-8200
Mailing Address - Fax:718-262-8651
Practice Address - Street 1:18215 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4853
Practice Address - Country:US
Practice Address - Phone:718-291-8200
Practice Address - Fax:718-262-8651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00318025Medicaid
NY00318025Medicaid
1204370001Medicare NSC