Provider Demographics
NPI:1801819875
Name:KOMANOFF CENTER FOR GERIATRIC & REHAB MEDICINE
Entity Type:Organization
Organization Name:KOMANOFF CENTER FOR GERIATRIC & REHAB MEDICINE
Other - Org Name:THE KOMANOFF CENTER FOR GERIATRIC & REHABILITATIVE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:SKUTZKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-897-1212
Mailing Address - Street 1:375 EAST BAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561
Mailing Address - Country:US
Mailing Address - Phone:516-897-1065
Mailing Address - Fax:516-897-1064
Practice Address - Street 1:375 EAST BAY DRIVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561
Practice Address - Country:US
Practice Address - Phone:516-897-1065
Practice Address - Fax:516-897-1064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2902302N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
009461OtherBLUE CROSS
NY00313988Medicaid
NY00313988Medicaid