Healthcare Provider Details

I. General information

NPI: 1750460358
Provider Name (Legal Business Name): NEW SURFSIDE NURSING HOME ADC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40-18 76STREET
ELMHURST NY
11373
US

IV. Provider business mailing address

2241 NEW HAVEN AVE
FAR ROCKAWAY NY
11691-2538
US

V. Phone/Fax

Practice location:
  • Phone: 718-471-3400
  • Fax: 718-471-2802
Mailing address:
  • Phone: 718-471-3400
  • Fax: 718-471-2802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number7003373N
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02700883
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: MRS. ELIZABETH DUNN
Title or Position: CONTROLLER
Credential:
Phone: 718-471-3400