Provider Demographics
NPI:1538588975
Name:CARDIFF BAY CENTER LLC
Entity type:Organization
Organization Name:CARDIFF BAY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-422-7817
Mailing Address - Street 1:5015 BEACH CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1110
Mailing Address - Country:US
Mailing Address - Phone:718-734-2000
Mailing Address - Fax:
Practice Address - Street 1:5015 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1110
Practice Address - Country:US
Practice Address - Phone:718-734-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00332834Medicaid
NY00332834Medicaid