Basic Information
| Provider Information | |||||||||
| NPI: | 1689159972 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELIZABETHTOWN OPCO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELIZABETHTOWN NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707656106 | ||||||||
| FaxNumber: | 2707376690 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707656106 | ||||||||
| FaxNumber: | 2707376690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | KELMAN | ||||||||
| AuthorizedOfficialFirstName: | MOSHE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2707656106 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
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 | 100161 | 01 | KY | LICENSE | OTHER | 7100578240 | 05 | KY | MEDICAID |