Provider Demographics
NPI:1295510402
Name:POTOMAC OPERATOR LLC
Entity type:Organization
Organization Name:POTOMAC OPERATOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BORUCH
Authorized Official - Middle Name:
Authorized Official - Last Name:MERMELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-299-2273
Mailing Address - Street 1:10714 POTOMAC TENNIS LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-4418
Mailing Address - Country:US
Mailing Address - Phone:301-299-2273
Mailing Address - Fax:
Practice Address - Street 1:10714 POTOMAC TENNIS LN
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-4418
Practice Address - Country:US
Practice Address - Phone:301-299-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility