Provider Demographics
NPI:1902988462
Name:HILLSIDE MANOR REHABILITATION AND EXTENDED CARE CENTER, LLC
Entity Type:Organization
Organization Name:HILLSIDE MANOR REHABILITATION AND EXTENDED CARE CENTER, LLC
Other - Org Name:HILLSIDE MANOR ADULT DAY HEALTH CARE PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:WISSMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-291-8200
Mailing Address - Street 1:18811 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-1935
Mailing Address - Country:US
Mailing Address - Phone:718-264-6700
Mailing Address - Fax:718-264-6777
Practice Address - Street 1:18811 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-1935
Practice Address - Country:US
Practice Address - Phone:718-264-6700
Practice Address - Fax:718-264-6777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02065901Medicaid