Healthcare Provider Details

I. General information

NPI: 1467198788
Provider Name (Legal Business Name): 11974 EDGEHILL TERRACE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11974 EDGEHILL TERRACE RD
PRINCESS ANNE MD
21853-2105
US

IV. Provider business mailing address

28 ROOSEVELT AVE
LAKEWOOD NJ
08701-5654
US

V. Phone/Fax

Practice location:
  • Phone: 410-651-0011
  • Fax:
Mailing address:
  • Phone: 732-744-4611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: YECHIEL HIRTH
Title or Position: CEO
Credential:
Phone: 732-744-4611