Basic Information
| Provider Information | |||||||||
| NPI: | 1467198788 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 11974 EDGEHILL TERRACE OPCO LLC | ||||||||
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| OtherOrganizationName: | MANOKIN NURSING AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14C 53RD ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112322644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8775670402 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11974 EDGEHILL TERRACE RD | ||||||||
| Address2: | |||||||||
| City: | PRINCESS ANNE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218532105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106510011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2022 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STERN | ||||||||
| AuthorizedOfficialFirstName: | SAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8775670402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 385H00000X | N | Respite Care Facility | Respite Care | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.