1019 Wicker Street Operating Company, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

1019 WICKER STREET OPERATING COMPANY, LLC

Doing business as

Elderwood at Ticonderoga

Practice address

1019 Wicker St
Ticonderoga, NY 12883-1039

Phone

(518) 585-2831

NPI assigned

Nov 14, 2016

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

Jeffrey Rubin

Title

Co-Chief Executive Officer

Phone

(716) 817-5075

Specialties & licenses 1

Addresses

Other names 1

• Elderwood at Ticonderoga 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 1871035485. Details of each certification follow.

• CCN 335482 Skilled nursing facility · Active · Details

Skilled nursing facility certification: CCN 335482

Legal name

1019 WICKER STREET OPERATING COMPANY LLC

Doing business as

ELDERWOOD AT TICONDEROGA

Certification status

Active

Provider type (POS)

Nursing home – SNF/NF dual certification

Participating since

Apr 1, 1976

Last certification

Jul 15, 2024

Beds

84

Ownership / control type

Limited Liability Corporation

Most recent change of ownership

Apr 10, 2018

Organization structure

LLCProprietary

Incorporated

Jun 27, 2016 in NY

Enrollment address

101 Adirondack Drive
Suite 3
Ticonderoga, NY 12883-1039

Nursing home name

ELDERWOOD AT TICONDEROGA

Affiliated entity

ELDERWOOD

Listed as

Elderwood at TiconderogaCCN 335482 · All quality measures

Overall star rating

2 of 5

Health inspections

2 of 5

Staffing

2 of 5

Quality measures

2 of 5

Type

Medicare and Medicaid

Ownership

For profit - Limited Liability company

Certified

Apr 1, 1976

Medicare certification status

ActiveFrom the Provider of Services file

Certified beds

8481.4 residents per day on average

Chain

Elderwood17 facilities in the chain

Penalties (3 years)

1Fines totaling $4,516

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 4

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.

• Loren M Allen, FNP

  • Family Nurse Practitioner
  • Mineville, NY
  • NPI 1770068371
  NPD (past)
• Kristin L Mack, DO

  • Family Medicine Physician
  • Malone, NY
  • NPI 1447539507
  NPD (past)
• Nicholas J Montello, DNP FNP

  • Family Nurse Practitioner
  • Ticonderoga, NY
  • NPI 1184285751
  NPD (past)
• Nathalie Abisror, MD

  • Family Medicine Physician
  • Castle Pines, CO
  • NPI 1336634922
  NPD (past)

Affiliated clinicians 3

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

• Kristin L Mack, DO

  • Family Medicine Physician
  • Malone, NY
  • NPI 1447539507

  Nursing home

  Care Compare affiliation
• Nicholas J Montello, DNP FNP

  • Family Nurse Practitioner
  • Ticonderoga, NY
  • NPI 1184285751

  Nursing home

  Care Compare affiliation
• Nathalie Abisror, MD

  • Family Medicine Physician
  • Castle Pines, CO
  • NPI 1336634922

  Nursing home

  Care Compare affiliation

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

{
    "created_epoch": "1479081600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674086400000",
    "number": "1871035485",
    "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": "1019 WICKER ST",
            "city": "TICONDEROGA",
            "state": "NY",
            "postal_code": "128831039",
            "telephone_number": "518-585-2831"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "1019 WICKER STREET OPERATING COMPANY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-11-14",
        "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"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Elderwood at Ticonderoga",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Elderwood at Ticonderoga",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Adirondack Optical Outfitters
• Carolyn A Andersen, TSHH
• Ashley Lauren Anderson, FNP
• Elizabeth Anderson, DNP FNP
• Karl Auerbach, M.D.

• Skilled Nursing Facility in Ticonderoga, NY
• Providers in Ticonderoga, 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.