Basic Information
| Provider Information | |||||||||
| NPI: | 1760851323 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINTERS HC OPERATOR LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WINTERS 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: | 506 VAN NESS ST | ||||||||
| Address2: | |||||||||
| City: | WINTERS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795674724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3257544566 | ||||||||
| FaxNumber: | 3257544634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2015 | ||||||||
| LastUpdateDate: | 06/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | FALKINBURG | ||||||||
| AuthorizedOfficialFirstName: | KARIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| 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 | 001027624 | 05 | TX | MEDICAID | 67-5847 | 01 | TX | MEDICARE ID | OTHER |