MEDICARE: SHADY KNOLL ACQUISITION OPERATOR 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	:	1225875362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADY KNOLL ACQUISITION OPERATOR LLC

Provider Business Mailing Address
First Line	:	20 E SUNRISE HWY FL 2
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-1260
Country	:	US
Telephone Number	:	516-705-4803
Fax Number	:

Provider Business Practice Location Address
First Line	:	41 SKOKORAT ST
Second Line	:
City	:	SEYMOUR
State	:	CT
Zip	:	06483-3826
Country	:	US
Telephone Number	:	203-881-2555
Fax Number	:	203-881-0853

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. MARC EPHRAM OSTREICHER
Credential	:
Telephone Number	:	516-705-4806

Provider Enumeration Date	:	07/15/2024
Last Update Date	:	07/15/2024

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