MEDICARE: HUNTSVILLE ROAD OPERATING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1164123592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUNTSVILLE ROAD OPERATING LLC

Provider Business Mailing Address
First Line	:	1999 CEDARBRIDGE AVE STE 3B
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-6915
Country	:	US
Telephone Number	:	732-366-5705
Fax Number	:

Provider Business Practice Location Address
First Line	:	235 HUNTSVILLE RD
Second Line	:
City	:	EUREKA SPRINGS
State	:	AR
Zip	:	72632-9572
Country	:	US
Telephone Number	:	479-253-7038
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	YISROEL GANZ
Credential	:
Telephone Number	:	732-366-5705

Provider Enumeration Date	:	03/13/2023
Last Update Date	:	01/25/2024

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