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General NPI Number Information
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NPI Number | 1558810259
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Entity Type | Organization
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Legal Business Name | CLOVER LAKE MANAGEMENT LLC
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Dates
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Enumeration Date | 09/23/2016
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Last Update Date | 09/23/2016
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Provider Practice Location Address
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Address Line | 838 FAIR ST
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City | CARMEL
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State | NY
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Zip | 10512-3085
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Country | US
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Telephone | 845-878-4111
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Fax |
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Provider Business Mailing Address
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Address Line | 838 FAIR ST
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City | CARMEL
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State | NY
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Zip | 10512-3085
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Country | US
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Telephone | 845-878-4111
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | CHARLES EDOUARD GROS
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Credential |
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Telephone | 718-360-8083
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 580F001
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License Number State | NY
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