Basic Information
| Provider Information | |||||||||
| NPI: | 1184090391 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINTERHAVEN HEALTHCARE RESIDENCE OPERATOR LLC | ||||||||
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| OtherOrganizationName: | WINTERHAVEN HEALTHCARE RESIDENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CLIFTON AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087013342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143963462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6534 STUEBNER AIRLINE RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770913207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136925137 | ||||||||
| FaxNumber: | 7136925155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2015 | ||||||||
| LastUpdateDate: | 06/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | FALKINBURG | ||||||||
| AuthorizedOfficialFirstName: | KARIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 2143963462 | ||||||||
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| 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 |
ID Information
| ID | Type | State | Issuer | Description | 004826 | 01 | TX | DADS | OTHER | 001027188 | 05 | TX | MEDICAID |