Provider Demographics
NPI:1992856751
Name:PROMENADE NURSING HOME, INC
Entity Type:Organization
Organization Name:PROMENADE NURSING HOME, INC
Other - Org Name:PROMENADE REHABILITATION AND HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-945-4600
Mailing Address - Street 1:140 BEACH 114TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2405
Mailing Address - Country:US
Mailing Address - Phone:718-945-4600
Mailing Address - Fax:718-634-8237
Practice Address - Street 1:140 BEACH 114TH ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2405
Practice Address - Country:US
Practice Address - Phone:718-945-4600
Practice Address - Fax:718-634-8237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7003386N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00308907Medicaid
NY00308907Medicaid