Healthcare Provider Details

I. General information

NPI: 1033110770
Provider Name (Legal Business Name): PECONIC LANDING AT SOUTHOLD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 12/18/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 BRECKNOCK RD
GREENPORT NY
11944-3117
US

IV. Provider business mailing address

1500 BRECKNOCK RD
GREENPORT NY
11944-3117
US

V. Phone/Fax

Practice location:
  • Phone: 631-477-3800
  • Fax: 631-477-3900
Mailing address:
  • Phone: 631-477-3800
  • Fax: 631-477-3900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: LISA BARBARA QUINN
Title or Position: CFO
Credential:
Phone: 631-477-3800