Basic Information
| Provider Information | |||||||||
| NPI: | 1629653589 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST MARKHAM STREET OPERATING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 MONMOUTH AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087013209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8482102175 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5720 W MARKHAM ST | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722053328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016646834 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2021 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | GANZ | ||||||||
| AuthorizedOfficialFirstName: | YISROEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | INCORPORATOR | ||||||||
| AuthorizedOfficialTelephone: | 7325232395 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.