Provider Demographics
NPI: | 1497331268 |
---|---|
Name: | 1801 WENTWORTH OPCO LLC |
Entity Type: | Organization |
Organization Name: | 1801 WENTWORTH OPCO LLC |
Other - Org Name: | |
Other - Org Type: | |
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 |
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: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1801 WENTWORTH RD |
Practice Address - Street 2: | |
Practice Address - City: | BALTIMORE |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21234-6128 |
Practice Address - Country: | US |
Practice Address - Phone: | 877-567-0402 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-03-22 |
Last Update Date: | 2021-03-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 314000000X | Nursing & Custodial Care Facilities | Skilled Nursing Facility | |
No | 313M00000X | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | |
No | 385H00000X | Respite Care Facility | Respite Care |