6012 Jefferson Boulevard Opco LLC
Organization Active NPI Skilled Nursing Facility · Frederick, MD
NPI 1952024176 · NPPES record last updated Sep 22, 2022
Key facts
- NPI
- 1952024176
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Skilled Nursing Facility 314000000X
- Legal business name
- 6012 JEFFERSON BOULEVARD OPCO LLC
- Practice address
- 6012 Jefferson Blvd
Frederick, MD 21703-6953 - Phone
- (732) 358-6883
- NPI assigned
- Sep 22, 2022
- Organization subpart
- No
Authorized official
- Name
- Sam Stern
- Title
- Cfo
- Phone
- (877) 567-0402
Owners & managing parties with NPI records 1
-
John Wah, M.D.
Facilities with the same owner 7
Practitioners 3
-
Dorothy M Seay, M.D.
-
John Wah, M.D.
Affiliated clinicians 2
-
John Wah, M.D.
Medicare Care Compare: Nursing home
- Listed as
- Autumn Lake Healthcare at Braddock Heights
- Overall star rating
- ★★★★☆ 4 of 5
- Health inspections
- ★★★★☆ 4 of 5
- Staffing
- ★★★☆☆ 3 of 5
- Quality measures
- ★★★★☆ 4 of 5
- Type
- Medicare and Medicaid
- Ownership
- For profit - Individual
- Certified
- Jun 1, 1989
- Medicare certification status
- Active
- Certified beds
- 65 · 57.1 residents per day on average
- Chain
- Autumn Lake Healthcare
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MD
Skilled nursing facility certification: CCN 215199
- Legal name
- 6012 JEFFERSON BOULEVARD OPCO LLC
- Doing business as
- AUTUMN LAKE HEALTHCARE AT BRADDOCK HEIGHTS
- Certification status
- Active
- Provider type (POS)
- Nursing home – SNF/NF dual certification
- Participating since
- Jun 1, 1989
- Last certification
- Aug 16, 2024
- Beds
- 65
- Ownership / control type
- Individual
- Multi-facility organization
- Autumn Lake Healthcare
- Organization structure
- LLC · Proprietary
- Incorporated
- Jan 1, 2023 in MD
- Enrollment address
- 6012 Jefferson Blvd
Frederick, MD 21703-6953 - Nursing home name
- AUTUMN LAKE HEALTHCARE AT BRADDOCK HEIGHTS
- Affiliated entity
- AUTUMN LAKE HEALTHCARE
All disclosed owners & managing parties 9
| Name | Role | Since | Share |
|---|---|---|---|
| M Meisels Family Holdings LLC |
5% Or Greater Direct Ownership Interest | Jan 1, 2023 | 30% |
| Adp of the SNF | Jan 1, 2023 | ||
| Brand Sonnenschine LLP |
Adp of the SNF | Jan 1, 2023 | |
| 6012 Jefferson Boulevard Holdco LLC |
5% Or Greater Direct Ownership Interest | Jan 1, 2023 | 100% |
| Adp of the SNF | Jan 1, 2023 | ||
| R Meisels Family Trust |
Adp of the SNF | Jan 1, 2023 | |
| Lisa McLaurin |
Operational/Managerial Control | Jan 1, 2023 | |
| Adp of the SNF | Jan 1, 2023 | ||
| Accurate Staffing LLC |
Adp of the SNF | Jan 1, 2023 | |
| As Family VB Holdings LLC |
5% Or Greater Direct Ownership Interest | Jan 1, 2023 | 70% |
| Adp of the SNF | Jan 1, 2023 | ||
| John a Wah |
Operational/Managerial Control | May 1, 2021 | |
| Adp of the SNF | May 1, 2021 | ||
| Mark Schwartz |
Corporate Officer |
Jan 1, 2023 | |
| Operational/Managerial Control | Jan 1, 2023 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20230227000440 | MD | Part a Provider - Skilled Nursing Facility | 1153794961 | Practice locations: Frederick, MD |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | Yes |
Addresses
Primary practice location
6012 Jefferson Blvd
Frederick, MD 21703-6953
Mailing address
14C 53Rd St
Brooklyn, NY 11232-2644
Phone (877) 567-0402
Other providers in Frederick, MD
- 1St Alliance Home Care LLC
- 2Xcell, Inc.
- 347 Ballenger Opco LLC
- 700 Toll House Avenue Operations LLC
- 700 Toll House Avenue Operations LLC
- A New Beginning
- A Perfect Fit LLC
- A&a Hearing Group, LLC
All providers in Frederick, MD · Skilled Nursing Facility in Maryland
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 22, 2022. 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.