Healthcare Provider Details

I. General information

NPI: 1255334082
Provider Name (Legal Business Name): PINEGROVE MANOR II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SAINT PAULS PL
GREAT NECK NY
11021-2636
US

IV. Provider business mailing address

15 SAINT PAULS PL
GREAT NECK NY
11021-2636
US

V. Phone/Fax

Practice location:
  • Phone: 516-466-3001
  • Fax: 516-466-7624
Mailing address:
  • Phone: 516-466-3001
  • Fax: 516-466-7624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2913301N
License Number StateNY

VIII. Authorized Official

Name: MS. KIMBERLY SODANO
Title or Position: ADMINISTRATOR
Credential:
Phone: 516-466-3001