Provider Demographics
NPI:1295734812
Name:HOLLIS PARK MANOR NURSING HOME, INC.
Entity type:Organization
Organization Name:HOLLIS PARK MANOR NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, FISCAL OVERSIGHT
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEWIRTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-588-8379
Mailing Address - Street 1:19106 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-1942
Mailing Address - Country:US
Mailing Address - Phone:718-479-1010
Mailing Address - Fax:718-464-8245
Practice Address - Street 1:19106 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-1942
Practice Address - Country:US
Practice Address - Phone:718-479-1010
Practice Address - Fax:718-464-8245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00310054Medicaid
NY335333Medicare UPIN
NY335333Medicare Oscar/Certification