Basic Information
| Provider Information | |||||||||
| NPI: | 1043672520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAYBROOK-P MILLVILLE OPCO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE GARDENS AT MILLVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 LORD AVE | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115591324 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 48 HAVEN LANE | ||||||||
| Address2: | |||||||||
| City: | MILLVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178460320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704585566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2016 | ||||||||
| LastUpdateDate: | 03/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | LAHASKY | ||||||||
| AuthorizedOfficialFirstName: | EPHRAM | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6467723668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.