170 West Avenue Operating Company, LLC
Organization Active NPI Skilled Nursing Facility · Brockport, NY
NPI 1245784271 · NPPES record last updated Jan 19, 2023
Key facts
- NPI
- 1245784271
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Skilled Nursing Facility 314000000X
- Legal business name
- 170 WEST AVENUE OPERATING COMPANY, LLC
- Practice address
- 170 West Ave
Brockport, NY 14420-1227 - Phone
- (585) 395-6052
- NPI assigned
- Aug 8, 2016
- Organization subpart
- No
Authorized official
- Name
- Dr. Jeffrey Rubin
- Title
- Co- Chief Executive Officer
- Phone
- (716) 817-5075
Practitioners 2
-
Albert F. Devlin, DO
-
Brian Hoon Son, D.O.
Affiliated clinicians 2
-
Albert F. Devlin, DO
-
Brian Hoon Son, D.O.
Medicare Care Compare: Nursing home
- Listed as
- Elderwood of Lakeside at Brockport
- Overall star rating
- ★★★★☆ 4 of 5
- Health inspections
- ★★★★☆ 4 of 5
- Staffing
- ★☆☆☆☆ 1 of 5
- Quality measures
- ★★★★★ 5 of 5
- Type
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Certified
- Dec 1, 1976
- Medicare certification status
- Active
- Certified beds
- 120 · 105.0 residents per day on average
- Chain
- Elderwood
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 33D0654836 | Elderwood of Lakeside at Brockport | Certificate of waiver | Mar 26, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NY
Skilled nursing facility certification: CCN 335569
- Legal name
- 170 WEST AVENUE OPERATING COMPANY LLC
- Doing business as
- ELDERWOOD OF LAKESIDE AT BROCKPORT
- Certification status
- Active
- Provider type (POS)
- Nursing home – SNF/NF dual certification
- Participating since
- Dec 1, 1976
- Last certification
- Apr 2, 2025
- Beds
- 120
- Ownership / control type
- Limited Liability Corporation
- Most recent change of ownership
- Jan 1, 2018
- Organization structure
- LLC · Proprietary
- Incorporated
- May 6, 2016 in NY
- Enrollment address
- 170 West Ave
Brockport, NY 14420-1227 - Nursing home name
- ELDERWOOD OF LAKESIDE AT BROCKPORT
- Affiliated entity
- ELDERWOOD
All disclosed owners & managing parties 5
| Name | Role | Since | Share |
|---|---|---|---|
| Kimberly S Klinetob |
W-2 Managing Employee |
Nov 1, 2017 | |
| Philip Quillard |
Operational/Managerial Control |
May 6, 2016 | |
| 170 West Avenue Operating Holdco LLC |
5% Or Greater Direct Ownership Interest | May 5, 2016 | 100% |
| Jeffrey Rubin |
5% Or Greater Indirect Ownership Interest | May 6, 2016 | 50% |
| Corporate Officer |
May 6, 2016 | 50% | |
| Operational/Managerial Control |
May 6, 2016 | 50% | |
| Warren D Cole |
5% Or Greater Indirect Ownership Interest | May 6, 2016 | 50% |
| Corporate Officer |
May 6, 2016 | 50% | |
| Operational/Managerial Control |
May 6, 2016 | 50% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20171016001528 | NY | Part a Provider - Skilled Nursing Facility | 8729354931 | Practice locations: Brockport, NY |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | Yes |
Addresses
Primary practice location
170 West Ave
Brockport, NY 14420-1227
Mailing address
500 Seneca St Ste 100
Buffalo, NY 14204-1963
Phone (716) 633-3900
Other names
- Elderwood of Lakeside at Brockport
Other providers in Brockport, NY
- Scarlett Aeckerle
- Agape Physical Therapy Services, PC
- Karori Mal Aggarwal
- Vinay Rajkumar Aggarwal
- Frances Ajayi
All providers in Brockport, NY · Skilled Nursing Facility in New York
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 19, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.