Water Castle Enrollment — demonstration report. Synthetic data only; not a filing.
Client confirmation packet
MTR-1001 · Northbridge Demonstration Facility · WC-SNF-300 revalidation
Client confirmation packet
Each value below is presented for client confirmation before signature. Sensitive values stay masked.
| Legal business name | Northbridge Demonstration Facility LLC | IRS CP-575, p. 1 |
| Doing-business-as name | Northbridge Demonstration Facility | State licence, p. 1 |
| Employer identification number | 00-DEMO001 | IRS CP-575, p. 1 |
| CMS certification number | 31-DEMO01 | PECOS enrollment snapshot, p. 2 |
| National provider identifier | 80-DEMO-0001 | NPPES confirmation, p. 1 |
| Entity type | Limited liability company | Operating agreement, p. 1 |
| Certified beds | 120 | State licence, p. 1 |
| Practice location | Lakeside, NJ | State licence, p. 1 |
| State licence number | NJ-LTC-DEMO-118 | State licence copy, p. 1 |
| State licence expiration | 2026-05-31 — expired | State licence copy, p. 1 |
| Owner — Miriam Levy | 60.00% direct | Operating agreement, §3.1 |
| Owner — Hector M. Villanueva | 30.00% direct | Operating agreement, §3.1 |