Healthcare Provider Details

I. General information

NPI: 1376943761
Provider Name (Legal Business Name): QUEENS BLVD EXT CARE FACILITY MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 QUEENS BLVD
WOODSIDE NY
11377-4965
US

IV. Provider business mailing address

6111 QUEENS BLVD
WOODSIDE NY
11377-4965
US

V. Phone/Fax

Practice location:
  • Phone: 718-205-0298
  • Fax:
Mailing address:
  • Phone: 718-205-0298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number703410N
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH MALONE
Title or Position: CFO
Credential:
Phone: 718-205-0298