112 Ski Bowl Road Operating Company, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

112 SKI BOWL ROAD OPERATING COMPANY, LLC

Doing business as

Elderwood at North Creek

Practice address

112 Ski Bowl Rd
North Creek, NY 12853-2607

Phone

(518) 251-2447

NPI assigned

Sep 29, 2017

Last updated

Jan 19, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Jeffrey Rubin

Title

Co-Chief Executive Officer

Phone

(716) 817-5075

Specialties & licenses 1

Addresses

Other names 1

• Elderwood at North Creek Doing business as

Medicare fee-for-service enrollment

Enrolled in NY

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1205345501. Details of each certification follow.

• CCN 335429 Skilled nursing facility · Active · Details

Skilled nursing facility certification: CCN 335429

Legal name

112 SKI BOWL ROAD OPERATING COMPANY, LLC

Doing business as

ELDERWOOD AT NORTH CREEK

Certification status

Active

Provider type (POS)

Nursing home – SNF/NF dual certification

Participating since

Oct 2, 1974

Last certification

Sep 20, 2024

Beds

82

Ownership / control type

Limited Liability Corporation

Organization structure

LLCProprietary

Incorporated

Apr 6, 2017 in NY

Enrollment address

112 Ski Bowl Rd
North Creek, NY 12853-2607

Nursing home name

ELDERWOOD AT NORTH CREEK

Affiliated entity

ELDERWOOD

Listed as

Elderwood at North CreekCCN 335429 · All quality measures

Overall star rating

2 of 5

Health inspections

3 of 5

Staffing

1 of 5

Quality measures

2 of 5

Type

Medicare and Medicaid

Ownership

For profit - Limited Liability company

Certified

Oct 2, 1974

Medicare certification status

ActiveFrom the Provider of Services file

Certified beds

8273.5 residents per day on average

Chain

Elderwood17 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

All disclosed owners & managing parties 5

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jennifer L Donovan, DO

  • Family Medicine Physician
  • North Creek, NY
  • NPI 1710202544
  NPD (past)

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

• Jennifer L Donovan, DO

  • Family Medicine Physician
  • North Creek, NY
  • NPI 1710202544

  Nursing home

  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1506643200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674086400000",
    "number": "1205345501",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "500 SENECA ST STE 100",
            "city": "BUFFALO",
            "state": "NY",
            "postal_code": "142041963",
            "telephone_number": "716-633-3900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "112 SKI BOWL RD",
            "city": "NORTH CREEK",
            "state": "NY",
            "postal_code": "128532607",
            "telephone_number": "518-251-2447"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "112 SKI BOWL ROAD OPERATING COMPANY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-09-29",
        "last_updated": "2023-01-19",
        "certification_date": "2023-01-19",
        "status": "A",
        "authorized_official_last_name": "RUBIN",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_title_or_position": "CO-CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "716-817-5075",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Elderwood at North Creek",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Adirondack Tri-County Nursing and Rehabilitation Center, Inc
• Lori P Benton, L.M.T.
• Rebecca Lynn Compson, BA
• William A Conner, RPA-C
• Deidre M. Convery-Bernard, MS, CCC-SLP

• Skilled Nursing Facility in North Creek, NY
• Providers in North Creek, NY by specialty
• Skilled Nursing Facility in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 19, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.