Provider Demographics
NPI:1063026755
Name:PGN OP PARK LLC
Entity Type:Organization
Organization Name:PGN OP PARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-645-9800
Mailing Address - Street 1:525 CHESTNUT ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-2223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:328 W VINE ST
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:OH
Practice Address - Zip Code:43517-9600
Practice Address - Country:US
Practice Address - Phone:419-298-2321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility