Provider Demographics
NPI:1821086448
Name:WEDGEWOOD CARE CENTER INC
Entity Type:Organization
Organization Name:WEDGEWOOD CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAFI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTECHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-303-0100
Mailing Address - Street 1:199 COMMUNITY DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5502
Mailing Address - Country:US
Mailing Address - Phone:516-365-9229
Mailing Address - Fax:516-365-2381
Practice Address - Street 1:199 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5502
Practice Address - Country:US
Practice Address - Phone:516-365-9229
Practice Address - Fax:516-365-2381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
NY2951306N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00312354Medicaid
NY335250Medicare ID - Type Unspecified