=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346376373
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSPECT PARK NURSING HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2007
-----------------------------------------------------
Last Update Date | 11/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1455 CONEY ISLAND AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230-4713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-252-9800
-----------------------------------------------------
Fax | 718-951-6742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1455 CONEY ISLAND AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230-4713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-252-9800
-----------------------------------------------------
Fax | 718-951-6742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASST. ADM.
-----------------------------------------------------
Name | MR. JACK FELDMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-252-9800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 7001338N
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------