Basic Information
Provider Information
NPI: 1003386780
EntityType: 2
ReplacementNPI:  
OrganizationName: POST-ACUTE CARE CENTER OPCO LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
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Credential:  
OtherOrganizationName: AUTUMN LAKE HEALTHCARE POST ACUTE CARE CENTER
OtherOrganizationType: 3
OtherLastName:  
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Mailing Information
Address1: 14C 53RD ST STE 220
Address2:  
City: BROOKLYN
State: NY
PostalCode: 112322644
CountryCode: US
TelephoneNumber: 8775670402
FaxNumber:  
Practice Location
Address1: 5009 FRANKFORD AVENUE
Address2:  
City: BALTIMORE
State: MD
PostalCode: 212065353
CountryCode: US
TelephoneNumber: 4103254000
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/26/2018
LastUpdateDate: 02/06/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: STERN
AuthorizedOfficialFirstName: SAM
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CFO
AuthorizedOfficialTelephone: 8775670402
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential:  
NPICertificationDate: 02/06/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
313M00000X  N Nursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility 
385H00000X  N Respite Care FacilityRespite Care 
314000000X  Y Nursing & Custodial Care FacilitiesSkilled Nursing Facility 

No ID Information.


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