Provider Demographics
NPI:1003222944
Name:CHESTERTOWN OPERATOR LLC
Entity Type:Organization
Organization Name:CHESTERTOWN OPERATOR LLC
Other - Org Name:AUTUMN LAKE HEALTHCARE AT CHESTERTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-567-0402
Mailing Address - Street 1:14C 53RD ST STE 224N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11232-2644
Mailing Address - Country:US
Mailing Address - Phone:718-567-0400
Mailing Address - Fax:
Practice Address - Street 1:415 MORGNEC RD
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1046
Practice Address - Country:US
Practice Address - Phone:410-778-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14006314000000X
385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No385H00000XRespite Care FacilityRespite Care