Healthcare Provider Details

I. General information

NPI: 1316765878
Provider Name (Legal Business Name): 300 PEARL STREET OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PEARL ST
BURLINGTON VT
05401-8531
US

IV. Provider business mailing address

290 CENTRAL AVE STE 107
LAWRENCE NY
11559-8507
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-4200
  • Fax:
Mailing address:
  • Phone: 516-430-5735
  • Fax: 781-729-3817

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: YEHUDA A RAINDEL
Title or Position: CFO
Credential:
Phone: 516-430-5735