Provider Demographics
NPI:1124563994
Name:PEARL VALLEY REHABILITATION AND NURSING AT LAKE PARK, LLC
Entity Type:Organization
Organization Name:PEARL VALLEY REHABILITATION AND NURSING AT LAKE PARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER (GREATER THAN 5 PERCENT)
Authorized Official - Prefix:
Authorized Official - First Name:YAAKOV
Authorized Official - Middle Name:
Authorized Official - Last Name:DORFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:551-206-2647
Mailing Address - Street 1:1576 E 27TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1304 S MARKET ST
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:IA
Practice Address - Zip Code:51347-1060
Practice Address - Country:US
Practice Address - Phone:712-832-3691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility