Provider Demographics
NPI:1205526324
Name:MEDINA BSD OPCO LLC
Entity type:Organization
Organization Name:MEDINA BSD OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATTISYAHU
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSSBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-608-9064
Mailing Address - Street 1:5140 US HIGHWAY 9 STE 1
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-3357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 MINER DR
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1472
Practice Address - Country:US
Practice Address - Phone:330-725-7550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility