MEDICARE: HOLLIS PARK 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

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	:	1295734812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLIS PARK MANOR NURSING HOME, INC.

Provider Business Mailing Address
First Line	:	19106 HILLSIDE AVE
Second Line	:
City	:	HOLLIS
State	:	NY
Zip	:	11423-1942
Country	:	US
Telephone Number	:	718-479-1010
Fax Number	:	718-464-8245

Provider Business Practice Location Address
First Line	:	19106 HILLSIDE AVE
Second Line	:
City	:	HOLLIS
State	:	NY
Zip	:	11423-1942
Country	:	US
Telephone Number	:	718-479-1010
Fax Number	:	718-464-8245

Authorized Official
Title or Position	:	MANAGER, FISCAL OVERSIGHT
Name	:	MR. JONATHAN GEWIRTZ
Credential	:
Telephone Number	:	914-588-8379

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	06/29/2015

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