Healthcare Provider Details

I. General information

NPI: 1184834723
Provider Name (Legal Business Name): MIRIAM ROZENBERG ET AL LILY POND NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 LILY POND AVE
STATEN ISLAND NY
10305-4608
US

IV. Provider business mailing address

150 LILY POND AVE
STATEN ISLAND NY
10305-4608
US

V. Phone/Fax

Practice location:
  • Phone: 718-981-5300
  • Fax: 718-727-8103
Mailing address:
  • Phone: 718-981-5300
  • Fax: 718-727-8103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number314000000X
License Number StateNY

VIII. Authorized Official

Name: MR. EDWARD C ERONINI
Title or Position: ADMINISTRATOR
Credential: NYS LNHA
Phone: 718-981-5300