Healthcare Provider Details

I. General information

NPI: 1821103813
Provider Name (Legal Business Name): MICHAEL TENENBAUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 BEACH 68TH ST
ARVERNE NY
11692-1407
US

IV. Provider business mailing address

430 BEACH 68TH ST
ARVERNE NY
11692-1407
US

V. Phone/Fax

Practice location:
  • Phone: 718-474-5200
  • Fax: 718-474-5214
Mailing address:
  • Phone: 718-474-5200
  • Fax: 718-474-5214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number7003330N
License Number StateNY

VIII. Authorized Official

Name: JACOB PERLES
Title or Position: ADMINISTRATOR
Credential:
Phone: 718-474-5200