Provider Demographics
NPI:1922004860
Name:MENORAH HOME & HOSPITAL FOR THE AGED & INFIRM
Entity Type:Organization
Organization Name:MENORAH HOME & HOSPITAL FOR THE AGED & INFIRM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-491-7209
Mailing Address - Street 1:1516 ORIENTAL BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2328
Mailing Address - Country:US
Mailing Address - Phone:718-646-4441
Mailing Address - Fax:
Practice Address - Street 1:1516 ORIENTAL BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2328
Practice Address - Country:US
Practice Address - Phone:718-646-4441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7001372N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00708181Medicaid
NY007917OtherBC/BS PROVIDER #
NY00708181Medicaid