Provider Demographics
NPI:1629339478
Name:AVALON GARDENS
Entity Type:Organization
Organization Name:AVALON GARDENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AKIVA
Authorized Official - Middle Name:FOGEL
Authorized Official - Last Name:FOGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-724-2200
Mailing Address - Street 1:211 SYMPHONY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1318
Mailing Address - Country:US
Mailing Address - Phone:631-642-7006
Mailing Address - Fax:
Practice Address - Street 1:7 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1626
Practice Address - Country:US
Practice Address - Phone:631-724-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1952813140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric