Provider Demographics
NPI:1184090391
Name:WINTERHAVEN HEALTHCARE RESIDENCE OPERATOR LLC
Entity type:Organization
Organization Name:WINTERHAVEN HEALTHCARE RESIDENCE OPERATOR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FALKINBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-396-3462
Mailing Address - Street 1:111 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-3342
Mailing Address - Country:US
Mailing Address - Phone:214-396-3462
Mailing Address - Fax:
Practice Address - Street 1:6534 STUEBNER AIRLINE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77091-3207
Practice Address - Country:US
Practice Address - Phone:713-692-5137
Practice Address - Fax:713-692-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-11
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004826OtherDADS
TX001027188Medicaid
675686Medicare Oscar/Certification