1477071371 NPI number — EDGEWOOD MANOR OF WELLSTON LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477071371 NPI number — EDGEWOOD MANOR OF WELLSTON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDGEWOOD MANOR OF WELLSTON LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EDGEWOOD MANOR OF WELLSTON
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477071371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1535 ROCKAWAY PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11236-4001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 NORTH PARK AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLSTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-384-5611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SHERMAN
Authorized Official First Name:
ALEXANDER
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
718-688-8760

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1225N . This is a "ODH HOME NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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