NPIMap

Organization Active NPI

South Shore Nursing and Rehabilitation LLC

  • Skilled Nursing Facility
  • South Shore, KY
National Provider Identifier
1609421676
Registry record updated Jul 20, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
SOUTH SHORE NURSING AND REHABILITATION LLC
Practice address
405 SM Roberson Dr
South Shore, KY 41175-9678
Phone
(606) 932-3127
NPI assigned
Aug 7, 2019
Last updated
Jul 20, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 20, 2023

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

Authorized official

Name
Paul Pruitt
Title
Officer
Phone
(317) 288-4029

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

405 SM Roberson Dr
South Shore, KY 41175-9678

Mailing address

100 Boulevard of Americas
Lakewood, NJ 08701-4585
Phone (732) 961-8400

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20191105000077 KY Part A Provider - Skilled Nursing Facility 0446582803 Practice locations: South Shore, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609421676. Details of each certification follow.

Skilled nursing facility certification: CCN 185282

Legal name
SOUTH SHORE NURSING AND REHABILITATION LLC
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jul 21, 1991
Last certification
Nov 10, 2021
Beds
60
Ownership / control type
Limited Liability Corporation
Multi-facility organization
Bluegrass Consulting Group
Organization structure
LLCProprietary
Incorporated
Jul 25, 2019 in IN
Enrollment address
405 SM Roberson Dr
South Shore, KY 41175-9678
Nursing home name
SOUTH SHORE NURSING AND REHABILITATION
Affiliated entity
DAVID MARX

Care Compare: Nursing home

Medicare Care Compare
Listed as
South Shore Nursing and RehabilitationCCN 185282 · All quality measures
Overall star rating
4 of 5
Health inspections
4 of 5
Staffing
2 of 5
Quality measures
2 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Jul 21, 1991
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
6053.4 residents per day on average
Chain
David Marx10 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
David Alexander Individual Operational/Managerial Control May 1, 2023
Adp of the SNF May 1, 2023
South Shore Nursing and Rehabilitation Holdings LLC Organization, South Shore, KY LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jul 25, 2019 100%
405 SM Roberson Dr SNF Realty LLC Organization, Fresh Meadows, NY LLC Operational/Managerial Control Sep 1, 2019
Adp of the SNF Sep 1, 2019
Kentucky SNF Realty Holdings LLC Organization, Fresh Meadows, NY LLC Adp of the SNF Sep 1, 2019
Mary Warnock Individual Operational/Managerial Control Jan 1, 2025
Adp of the SNF Jan 1, 2025
Angela Rewa Individual Operational/Managerial Control Oct 23, 2023
Adp of the SNF Oct 23, 2023
Robert Laron Russell Individual Operational/Managerial Control Apr 8, 2024
Adp of the SNF Apr 8, 2024
405 SM Roberson Dr SNF Realty Holdings LLC Organization, Fresh Meadows, NY LLC, Holding company Adp of the SNF Sep 1, 2019
Paul Pruitt Individual Operational/Managerial Control May 1, 2023
Managing Control - Governing BodyCeo May 1, 2023
Adp of the SNF May 1, 2023
MDG Real Estate Global Limited Organization, Fresh Meadows, NY Corporation Adp of the SNF Sep 1, 2019
Bluegrass Consulting Group LLC Organization, Westfield, IN LLC, Management services company Operational/Managerial Control Sep 1, 2019
Adp of the SNF Jul 17, 2025
Margaret Chamberlain Individual Operational/Managerial Control Sep 11, 2023
Adp of the SNF Sep 11, 2023
Anzhelika Shatrov Individual Operational/Managerial Control Dec 2, 2024
Adp of the SNF Dec 2, 2024
David Marx Individual 5% Or Greater Indirect Ownership Interest Jul 25, 2019 100%
Operational/Managerial Control Sep 1, 2019
Adp of the SNF Sep 1, 2019
Kari D Shields Individual Operational/Managerial Control Jan 1, 2025
Adp of the SNF Jan 1, 2025
Organization, Lakewood, NJ Consulting firm Adp of the SNF Jul 17, 2025
Eric Wolfe Individual Operational/Managerial Control Sep 11, 2023
Adp of the SNF Sep 11, 2023

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 8

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 2

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.

Affiliated clinicians 1

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

NPI Registry JSON

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

{
    "created_epoch": "1565136000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1689811200000",
    "number": "1609421676",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 BOULEVARD OF AMERICAS",
            "city": "LAKEWOOD",
            "state": "NJ",
            "postal_code": "087014585",
            "telephone_number": "732-961-8400"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "405 SM ROBERSON DR",
            "city": "SOUTH SHORE",
            "state": "KY",
            "postal_code": "411759678",
            "telephone_number": "606-932-3127"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH SHORE NURSING AND REHABILITATION LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-07",
        "last_updated": "2023-07-20",
        "certification_date": "2023-07-20",
        "status": "A",
        "authorized_official_last_name": "PRUITT",
        "authorized_official_first_name": "PAUL",
        "authorized_official_title_or_position": "OFFICER",
        "authorized_official_telephone_number": "317-288-4029"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in South Shore, KY

Sources for this page

Verify at the official NPI Registry.