Provider Demographics
NPI:1568459279
Name:JBG HOLDING COMPANY LLC
Entity Type:Organization
Organization Name:JBG HOLDING COMPANY LLC
Other - Org Name:WOODHAVEN NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-473-7100
Mailing Address - Street 1:1360 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3078
Mailing Address - Country:US
Mailing Address - Phone:631-473-7100
Mailing Address - Fax:631-473-7118
Practice Address - Street 1:1360 ROUTE 112
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3078
Practice Address - Country:US
Practice Address - Phone:631-473-7100
Practice Address - Fax:631-473-7118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5151316N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00308470Medicaid
NY5151316NOtherNY OPERATING CERTIFICATE
NY4053760001Medicare NSC
NY335514001Medicare ID - Type UnspecifiedMEDICARE