Healthcare Provider Details

I. General information

NPI: 1609450386
Provider Name (Legal Business Name): 200 WHITMAN AVENUE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WHITEMAN AVE
ELKINS WV
26241-3400
US

IV. Provider business mailing address

14C 53RD ST
BROOKLYN NY
11232-2644
US

V. Phone/Fax

Practice location:
  • Phone: 877-567-0402
  • Fax:
Mailing address:
  • Phone: 877-567-0402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SAM STERN
Title or Position: CFO
Credential:
Phone: 877-567-0402