Healthcare Provider Details

I. General information

NPI: 1154158657
Provider Name (Legal Business Name): TWIN LAKES EXTENDED CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S EADS AVE
PARIS IL
61944-1938
US

IV. Provider business mailing address

7B MEDICAL PARK DR
POMONA NY
10970-3516
US

V. Phone/Fax

Practice location:
  • Phone: 217-465-5395
  • Fax: 217-463-2242
Mailing address:
  • Phone: 845-414-3300
  • Fax: 845-517-4796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN FRIEDMAN
Title or Position: CFO
Credential:
Phone: 845-414-3300