=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023568185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKSHORE HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2016
-----------------------------------------------------
Last Update Date | 01/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1535 ROCKAWAY PKWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11236-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-927-6346
-----------------------------------------------------
Fax | 718-272-2166
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1535 ROCKAWAY PKWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11236-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-927-6346
-----------------------------------------------------
Fax | 718-272-2166
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTROLLER
-----------------------------------------------------
Name | NATHAN ZELCER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-927-6346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 7001641
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------