Provider Demographics
NPI:1629965918
Name:MEADOWBROOK OPERATING LLC
Entity type:Organization
Organization Name:MEADOWBROOK OPERATING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHLOMO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOEHM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-360-8083
Mailing Address - Street 1:460 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096-1702
Mailing Address - Country:US
Mailing Address - Phone:718-360-8083
Mailing Address - Fax:
Practice Address - Street 1:154 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1302
Practice Address - Country:US
Practice Address - Phone:518-563-5440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02994732Medicaid