MEDICARE: MAYBROOK-P PALMYRA OPCO, 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	:	1851752430
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAYBROOK-P PALMYRA OPCO, LLC

Provider Business Mailing Address
First Line	:	34 LORD AVE
Second Line	:
City	:	LAWRENCE
State	:	NY
Zip	:	11559-1324
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	341 N RAILROAD ST
Second Line	:
City	:	PALMYRA
State	:	PA
Zip	:	17078-1328
Country	:	US
Telephone Number	:	717-838-3011
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	EPHRAM M LAHASKY
Credential	:
Telephone Number	:	646-772-3668

Provider Enumeration Date	:	03/10/2016
Last Update Date	:	03/10/2016

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