Provider Demographics
NPI:1093286585
Name:PORT JEFFERSON OPERATING LLC
Entity Type:Organization
Organization Name:PORT JEFFERSON OPERATING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER / MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-596-1800
Mailing Address - Street 1:150 DARK HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2048
Mailing Address - Country:US
Mailing Address - Phone:631-473-5400
Mailing Address - Fax:
Practice Address - Street 1:150 DARK HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2048
Practice Address - Country:US
Practice Address - Phone:631-473-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility