1019 Wicker Street Operating Company, LLC
Organization Active NPI Skilled Nursing Facility · Ticonderoga, NY
NPI 1871035485 · NPPES record last updated Jan 19, 2023
Key facts
- NPI
- 1871035485
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Skilled Nursing Facility 314000000X
- Legal business name
- 1019 WICKER STREET OPERATING COMPANY, LLC
- Practice address
- 1019 Wicker St
Ticonderoga, NY 12883-1039 - Phone
- (518) 585-2831
- NPI assigned
- Nov 14, 2016
- Organization subpart
- No
Authorized official
- Name
- Jeffrey Rubin
- Title
- Co-Chief Executive Officer
- Phone
- (716) 817-5075
Practitioners 4
-
Loren M Allen, FNP
-
Kristin L Mack, DO
-
Nicholas J Montello, DNP FNP
-
Nathalie Abisror, MD
Affiliated clinicians 3
-
Kristin L Mack, DO
-
Nicholas J Montello, DNP FNP
-
Nathalie Abisror, MD
Medicare Care Compare: Nursing home
- Listed as
- Elderwood at Ticonderoga
- 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
- Active
- Certified beds
- 84 · 81.4 residents per day on average
- Chain
- Elderwood
- Penalties (3 years)
- 1 · fines totaling $4,516
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 33D0164908 | Elderwood at Ticonderoga | Certificate of waiver | Mar 26, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NY
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
- LLC · Proprietary
- 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
All disclosed owners & managing parties 5
| Name | Role | Since | Share |
|---|---|---|---|
| Philip Quillard |
Corporate Officer |
Jun 26, 2016 | |
| Operational/Managerial Control |
Jun 26, 2016 | ||
| Douglas E Cosey |
W-2 Managing Employee |
Apr 13, 2020 | |
| 1019 Wicker Street Operating Holdco LLC |
5% Or Greater Direct Ownership Interest | Jun 27, 2016 | 100% |
| Jeffrey Rubin |
5% Or Greater Indirect Ownership Interest | Jun 26, 2016 | 50% |
| Corporate Officer |
Jun 26, 2016 | 50% | |
| Operational/Managerial Control |
Jun 26, 2016 | 50% | |
| Warren D Cole |
5% Or Greater Indirect Ownership Interest | Jun 26, 2016 | 50% |
| Corporate Officer |
Jun 26, 2016 | 50% | |
| Operational/Managerial Control |
Jun 26, 2016 | 50% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20180420000477 | NY | Part a Provider - Skilled Nursing Facility | 9133482342 | Practice locations: Ticonderoga, NY |
National Provider Directory
Locations
101 Adirondack Dr
Ticonderoga, NY 12883
Phone (518) 585-3700
101 Adirondack Dr
Ste 3
Ticonderoga, NY 12883
Phone (518) 585-3777
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | Yes |
Addresses
Primary practice location
1019 Wicker St
Ticonderoga, NY 12883-1039
Mailing address
500 Seneca St Ste 100
Buffalo, NY 14204-1963
Phone (716) 633-3900
Other names
- Elderwood at Ticonderoga
Other providers in Ticonderoga, NY
- Adirondack Optical Outfitters
- Carolyn A Andersen
- Ashley Lauren Anderson
- Elizabeth Anderson
- Karl Auerbach
All providers in Ticonderoga, 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.