Provider Demographics
NPI:1548253313
Name:QUEENS BOULEVARD EXTENDED CARE FACILITY
Entity type:Organization
Organization Name:QUEENS BOULEVARD EXTENDED CARE FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-205-0287
Mailing Address - Street 1:6111 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4965
Mailing Address - Country:US
Mailing Address - Phone:718-205-0287
Mailing Address - Fax:718-205-1342
Practice Address - Street 1:6111 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4965
Practice Address - Country:US
Practice Address - Phone:718-205-0287
Practice Address - Fax:718-205-1342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7003390N313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01626686Medicaid
NY01710672Medicaid
NY7003390NMedicaid
NY01710672Medicaid
NY01626686Medicaid