Provider Demographics
NPI:1275733297
Name:SPLIT ROCK ADULT DAY HEALTH CARE
Entity Type:Organization
Organization Name:SPLIT ROCK ADULT DAY HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:AJ
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-670-6300
Mailing Address - Street 1:3525 BAYCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-5001
Mailing Address - Country:US
Mailing Address - Phone:718-798-8900
Mailing Address - Fax:855-570-0752
Practice Address - Street 1:3525 BAYCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-5001
Practice Address - Country:US
Practice Address - Phone:718-798-8900
Practice Address - Fax:855-570-0752
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPLIT ROCK NURSING AND REHAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-18
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7000384N261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01120103Medicaid