Healthcare Provider Details

I. General information

NPI: 1114922689
Provider Name (Legal Business Name): PENINSULA GENERAL NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50-15 BEACH CHANNEL DRIVE
FAR ROCKAWAY NY
11691
US

IV. Provider business mailing address

50-15 BEACH CHANNEL DRIVE
FAR ROCKAWAY NY
11691
US

V. Phone/Fax

Practice location:
  • Phone: 718-734-2000
  • Fax:
Mailing address:
  • Phone: 718-734-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number7003308N
License Number StateNY

VIII. Authorized Official

Name: MR. ALEXANDER SKUTZKA
Title or Position: ADMINISTRATOR
Credential:
Phone: 718-734-2000