Provider Demographics
NPI:1003543125
Name:WATERFORD OPCO LLC
Entity Type:Organization
Organization Name:WATERFORD OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:BENGIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-300-3878
Mailing Address - Street 1:2901 STIRLING RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-6529
Mailing Address - Country:US
Mailing Address - Phone:954-300-3878
Mailing Address - Fax:
Practice Address - Street 1:8333 W OKEECHOBEE RD
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-2109
Practice Address - Country:US
Practice Address - Phone:954-300-3787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility