Provider Demographics
NPI:1013280759
Name:2850 GRAND ISLAND BOULEVARD OPERATING COMPANY LLC
Entity Type:Organization
Organization Name:2850 GRAND ISLAND BOULEVARD OPERATING COMPANY LLC
Other - Org Name:ELDERWOOD AT GRAND ISLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-817-5075
Mailing Address - Street 1:500 SENECA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14204-1963
Mailing Address - Country:US
Mailing Address - Phone:716-633-3900
Mailing Address - Fax:
Practice Address - Street 1:2850 GRAND ISLAND BLVD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-1251
Practice Address - Country:US
Practice Address - Phone:716-773-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01148136Medicaid
335391Medicare PIN