Provider Demographics
NPI:1558810259
Name:CLOVER LAKE MANAGEMENT LLC
Entity Type:Organization
Organization Name:CLOVER LAKE MANAGEMENT LLC
Other - Org Name:PLAZA AT CLOVER LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDOUARD
Authorized Official - Last Name:GROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-360-8083
Mailing Address - Street 1:838 FAIR ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-3085
Mailing Address - Country:US
Mailing Address - Phone:845-878-4111
Mailing Address - Fax:
Practice Address - Street 1:838 FAIR ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-3085
Practice Address - Country:US
Practice Address - Phone:845-878-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY580F001310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03547748Medicaid