Healthcare Provider Details

I. General information

NPI: 1316308968
Provider Name (Legal Business Name): MAYBROOK-P AUDUBON OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S BROAD ST
LITITZ PA
17543-1808
US

IV. Provider business mailing address

34 LORD AVE
LAWRENCE NY
11559-1324
US

V. Phone/Fax

Practice location:
  • Phone: 717-626-0211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: EPHRAM M LAHASKY
Title or Position: MEMBER
Credential:
Phone: 646-772-3668