MEDICARE: 200 WHITMAN AVENUE OPCO LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	385H00000X	Respite Care
2	313M00000X	Nursing Facility/Intermediate Care Facility
3	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1609450386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	200 WHITMAN AVENUE OPCO LLC

Provider Business Mailing Address
First Line	:	14C 53RD ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11232-2644
Country	:	US
Telephone Number	:	877-567-0402
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 WHITEMAN AVE
Second Line	:
City	:	ELKINS
State	:	WV
Zip	:	26241-3400
Country	:	US
Telephone Number	:	877-567-0402
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	SAM STERN
Credential	:
Telephone Number	:	877-567-0402

Provider Enumeration Date	:	05/10/2021
Last Update Date	:	03/14/2022

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Directions to “200 WHITMAN AVENUE OPCO LLC ” Practice Location

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