- Enrollment id
- O20040419000276
- Enrollment state
- NY
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1720111479
- Multiple npi flag
- N
- Ccn
- 335819
- Associate id
- 7416942537
- Organization name
- PARK AVENUE OPERATING COMPANY LLC
- Doing business as name
- PARK AVENUE EXTENDED CARE FACILITY
- Incorporation date
- 2004-07-23
- Incorporation state
- NY
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- PARK AVENUE EXTENDED CARE FACILITY
- Address line 1
- 425 NATIONAL BLVD
- City
- LONG BEACH
- State
- NY
- Zip code
- 115612031