Provider Demographics
NPI:1184834723
Name:MIRIAM ROZENBERG ET AL LILY POND NURSING HOME
Entity Type:Organization
Organization Name:MIRIAM ROZENBERG ET AL LILY POND NURSING HOME
Other - Org Name:LILY POND NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:ERONINI
Authorized Official - Suffix:
Authorized Official - Credentials:NYS LNHA
Authorized Official - Phone:718-981-5300
Mailing Address - Street 1:150 LILY POND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4608
Mailing Address - Country:US
Mailing Address - Phone:718-981-5300
Mailing Address - Fax:718-727-8103
Practice Address - Street 1:150 LILY POND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-4608
Practice Address - Country:US
Practice Address - Phone:718-981-5300
Practice Address - Fax:718-727-8103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314000000X313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY335047Medicare Oscar/Certification