MEDICARE: SUNRISE MANOR NURSING HOME, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	5154321N	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073568671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE MANOR NURSING HOME, INC.

Provider Business Mailing Address
First Line	:	1325 BRENTWOOD RD
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-5704
Country	:	US
Telephone Number	:	631-665-4960
Fax Number	:	631-665-9411

Provider Business Practice Location Address
First Line	:	1325 BRENTWOOD RD
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-5704
Country	:	US
Telephone Number	:	631-665-4960
Fax Number	:	631-665-9411

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. DAVID LANDA
Credential	:
Telephone Number	:	917-607-7595

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	01/24/2012

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