Provider Demographics
NPI:1679797625
Name:FIELDSTON LODGE CARE CENTER
Entity type:Organization
Organization Name:FIELDSTON LODGE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, FISCAL OVERSIGHT
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEWIRTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-588-8379
Mailing Address - Street 1:666 KAPPOCK ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-7704
Mailing Address - Country:US
Mailing Address - Phone:917-549-1203
Mailing Address - Fax:718-884-3792
Practice Address - Street 1:666 KAPPOCK ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-7704
Practice Address - Country:US
Practice Address - Phone:917-549-1203
Practice Address - Fax:718-884-3792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7000385N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00310605Medicaid
NY335248Medicare ID - Type Unspecified